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A   TREATISE 


ORTHOPEDIC  SURGERY 


BY 


ROYAL  WHITMAN,  M.D. 


ASSISTANT    PROFESSOR    OF    ORTHOPEDIC    SURGERY    IN    THE   COLLEGE    OF    PHYSICIANS    AND    SURGEONS 

OF      COLUMBIA     UNIVERSITY,      NEW      YORK;     PROFESSOR    OF     ORTHOPEDIC    SURGERY    IN    THE 

NEW  YORK   POLYCLINIC  MEDICAL    SCHOOL    AND     HOSPITAL 

ASSOCIATE    SURGEON    TO   THE     HOSPITAL    FOR    RUPTURED   AND    CRIPPLED;     ORTHOPEDIC    SURGEON    TO 

THE    HOSPITAL    OF    ST.     JOHN'S    GUILD;    CONSULTING    SURGEON   TO    ST.    AGNES    HOSPITAL 

FOE   CRIPPLED   AND   ATYPICAL    CHILDREN,   WHITE    PLAINS,   AND    TO    THE 

NEW  YORK    HOME    FOR    DESTITUTE    CRIPPLED    CHILDREN 

MEMBER   OF    THE  ROYAL    COLLEGE    OF    SURGEONS   OF    ENGLAND;    MEMBER   AND   SOMETIME   PRESIDENT 

OF    THE    AMERICAN    ORTHOPEDIC  ASSOCIATION;    CORRESPONDING    MEMBER   OP    THE 

BRITISH    ORTHOPEDIC    SOCIETY;      MEMBER    OF    THE   NEW  YORK 

SURGICAL    SOCIETY',    ETC. 


FOURTH  EDITION,  REVISED  AND  ENLARGED 


ILLUSTRATED    WITH    SIX    HUNDRED    AND    ONE    ENGRAVINGS 


LEA   &    FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1910 


Entered   according  to  Act  of  Congress,  in  the  year  1910,  by 

LEA  &  FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


TO 

YIRGIL   P.   GIBNEY,  M.D.,  LL.D. 

THIS   VOLUME   IS   INSCRIBED 

AS   A   TOKEN   OF   FKIENDSHIP   ASSURED   BY   LONG   ASSOCIATION 

AND  OF   APPRECIATION   OF   HIS  EFFORTS 

FOR  THE   ADVANCEMENT  OF 

OETHOPEDIC   SUKGERY 


Digitized  by  tine  Internet  Arcinive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonorthop1910whit 


CONTENTS.  ix 

CHAPTER  VIII. 

NON-TUBERCULOUS    AFFECTIONS   OF   THE    HIP-JOINT. 

FAGE 

Statistics — Traumatisms  at  the  hip — Acute  infectious  arthritis — Acute 
epiphysitis — Subacute  arthritis — Gonorrhoeal  arthritis — Spontaneous 
dislocation — Extra-articular  disease — Bursitis — Malignant  disease 
at  the  hip-joint — Cysts  of  the  femur — Arthritis  deformans 409 

CHAPTER  IX. 

TUBERCULOUS   DISEASE   OF   THE   KNEE-JOINT. 

Pathology — Etiology — Statistics — Symptoms,  primary  and  secondary 
distortions — Shortening  and  lengthening — Diagnosis — Differential 
diagnosis — Treatment — Reduction  of  deformity — Forms  of  braces 
— Accessories  in  treatment — Extra-articular  disease — Abscess — 
Synovial  tuberculosis — Operative  treatment — arthrectomy — excision, 
amputation —  Prognosis — mortality —  functional  results  —  General 
conclusions   417 

CHAPTER  X. 

NON-TUBERCULOUS  AFFECTIONS  AND  DEFORMITIES  OF  THE  KNEE-JOINT. 

Injury  in  childhood — Acute  synovitis — Chronic  and  recurrent  synovitis 
—Incidental  synovitis—' '  Quiet  effusion '  '—Internal  derangement 
of  knee-joint — Loose  bodies  in  knee-joint — Displacement  of  semi- 
lunar cartilage — Hyperplasia — Prepatellar  bursitis — Pretibial  bursi- 
tis— Enlargement  of  superficial  pretibial  bursa — Injury  of  tibial 
tubercle — Burs^  and  cysts  in  the  popliteal  region — Acquired  genu 
recurvatum — Congenital  genu  recurvatum — Rudimentary  or  absent 
patella — Congenital  and  acquired  displacement  of  patella — Slipping 
patella — Elongation  of  the  ligamentum  patellae — Snapping  knee — 
Congenital  contraction  at  the  knee — General  contractions 446 

CHAPTER  XI. 

DISEASES   AND  INJURIES   OF   THE  ANKLE-JOINT. 

Tuberculous  disease  —  Pathology—  Etiology—  Statistics  —  Symptoms  — 
Diagnosis— Treatment— Prognosis— Tuberculous  disease  of  the 
tarsus — Statistics — Treatment — Sprain  of  the  ankle — Chronic  sprain 
— Fracture  of  tarsal  bones — Tenosynovitis — Swelling  about  the 
ankles 4g3 

CHAPTER  XII. 

DISEASES   AND  INJURIES  OF   THE   ARTICULATIONS   OF  THE 
UPPER    EXTREMITY. 

Tuberculous  disease  of  the  shoulder- joint — Pathology— Statistics- 
Symptoms — Treatment — Prognosis — Tuberculous  disease  of  the 
elbow-joint  —  Pathology  —  Statistics  —  Symptoms  —  Treatment  — 
Prognosis — Tuberculous    disease    of    the    wrist-joint — Symptoms — 


X  CONTENTS. 

PAGE 

Treatment  —  Prognosis  —  Spina  ventosa  —  Periarthritis  of  the 
shoulder — Chronic  bursitis  at  the  shoulder — Sprain  of  the  wrist — - 
Acute  and  chronic  tenosynovitis  at  the  wrist 481 

CHAPTEE  XIII. 

DEFORMITIES  OF  THE  UPPER  EXTREMITY. 

Congenital  dislocation  of  the  shoulder — Obstetrical  paralysis  and  dis- 
location— Treatment — ^Operation  on  brachial  plexus — Eecurrent 
dislocation  of  the  shoulder — Congenital  deformities  of  the  elbow — 
Congenital  pronation  of  the  forearm — Cubitus  valgus — Cubitus 
varus — Subluxation  of  the  wrist — Congenital  deformities  at  the 
wrist  — Club-hand  — Varieties  —  Treatment  —  Club-hand  associated 
with  defective  development — Contractions  and  distortions  of  the 
fingers — Webbed  fingers — Congenital  displacement  of  phalanges — 
Trigger  finger — Mallet,  finger — Base-ball  finger — Dupuytren's  con- 
traction— Ischemic  paralysis  and  contraction 498 

CHAPTEE  XIV. 

CONGENITAL   AND   ACQUIRED   AFFECTIONS    LEADING   TO    GENERAL 
DISTORTIONS. 

Ehachitis — Etiology— Pathology — Symptoms,  deformities — Prognosis- 
Treatment — ' '  Late  rickets ' ' — Chondrodystrophia — Infantile  scor- 
butus —  Fragilitas  ossium  —  Osteomalacia  —  Osteitis  deformans  — 
Secondary  hypertrophic  osteo-arthropathy — Acromegalia.  . 519 

CHAPTEE  XV. 

CONGENITAL  DISLOCATION   OF   THE   HIP   AND   COXA  VARA. 

Congenital  dislocation  of  the  hip- joint — Statistics — Pathology — Etiology 
— Symptoms,  unilateral,  bilateral  and  anterior  dislocation — Supra- 
cotyloid  displacement — Diagnosis — Differential  diagnosis — Treat- 
ment— the  Lorenz  operation — Details  and  modifications — Treatment 
of  older  subjects — Treatment  in  infancy — Prognosis — Arthrotomy — 
Osteotomy — Open  operation  of  Hoffa-Lorenz — Eeview  of  treatment 
— Palliative  treatment — Congenital  subluxation  of  the  hip — Snap- 
ping hip — Coxa  vara — Pathology — Etiology — Statistics — Symptoms, 
unilateral,  bilateral — Diagnosis — Treatment — mechanical — operative 
—Forcible  abduction — Osteotomy — Cuneiform —  Linear —  Fracture 
of  the  neck  of  the  femur — Traumatic  coxa  vara — Simple  fracture — 
Epiphyseal  fracture — Fracture  in  adult  life — The  author's  treat- 
ment for  complete — for  impacted — Coxa  valga 536 

CHAPTEE  XVI. 

DEFORMITIES    OP    THE   BONES    OF    THE    LOWER    EXTREMITY. 

Bow-leg — Knock-knee — Statistics — Etiology — The  outgrowth  of  defor- 
mity— Genu  valgum — Description — Attitudes — Secondary  deform- 
ities— Gait — Unilateral     deformity — Pathology — Treatment — expec- 


CONTENTS.  XI 

PAGE 

tant — mechanical — operative — Genu  varum,  varieties — Symptoms 
— Treatment — expectant — mechanical  —  operative  — Anterior  bow- 
leg— General  rhachitic  distortions 594 

CHAPTER  XVII. 

DISEASES    OF    THE   NERVOUS    SYSTEM. 

Acute  anterior  poliomyelitis — Pathology — Etiology — Statistics — Symp- 
toms— Diagnosis — Prognosis — Causes  of  Deformity — Deformity  in 
various  regions — Subluxation — Eetardation  of  growth — Principles 
of  Treatment — Treatment,  mechanical,  operative — Tendon  and  mus- 
cle  transplantation — Arthrodesis — Nerve    grafting — Eecapitulation.  624 

CHAPTEE  XVIII. 

DISEASES   OF   THE   NERVOUS    SYSTEM    (CONTINUED). 

Cerebral  paralysis  of  childhood — Description — Distribution — Etiology — 
Pathology — Symptoms — Congenital  weakness  and  paralysis — Ac- 
quired paralysis — Hemiplegia — Paraplegia — Treatment,  mechanical, 
operative — Prognosis — Spastic  spinal  paraplegia — Progressive  mus- 
cular atrophy — Varieties — Hereditary  ataxia — Neuritis — Hysterical 
and  functional  affections  of  the  joints — Neurotic  spine — Hysterical 
spine — ' '  Hysterical  scoliosis  ' ' — ' '  Hysterical  hip  ' ' — Hysterical 
talipes — Neurotic  joints • 651) 

CHAPTEE  XIX. 

CONGENITAL  AND   ACQUIRED  TORTICOLLIS. 

Description — Statistics — Congenital  torticollis  —  Etiology —  Hsematoma 
of  the  sternomastoid  muscle — Acquired  torticollis — Varieties — 
Acute  torticollis — Etiology — Symptoms — Diagnosis — Treatment  of 
chronic  torticollis — mechanical,  operative — Treatment  of  acute 
torticollis  —  Spasmodic  torticollis  —  Etiology —  Pathology —  Treat- 
ment— Exceptional  forms  of  torticollis — paralytic — diphtheritic — ■ 
cervical  opisthotonos — rhachitic — ocular — psychical 671 

CHAPTEE  XX. 

DISABILITIES    AND   DEFORMITIES    OF    THE    FOOT, 

Oeneral  description  of  the  foot  and  of  its  functions,  the  arches,  the  foot 
as  a  passive  support,  in  activity — Improper  postui;es — Movements 
— Function  of  the  muscles — Strength  of  the  muscles — The  foot  as  a 
mechanism^The  weak  foot  or  so-called  flat-foot — Description — 
Anatomy —  Pathology — Etiology — Statistics — Symptoms — Diagnosis 
— Varieties — Weak  foot  in  childhood — Exceptional  forms — Treat- 
ment— Preventive — Exercises — Support — Construction  of  brace — 
The  rigid  weak  foot — Forcible  correction  of  deformity — Subsequent 
treatment — Adjuncts  in  treatment — Operative  treatment 694 


Xll  CONTENTS. 

CHAPTER  XXI. 

DISABILITIES  AXD  DEFORMITIES  OF  THE  FOOT    (CONTINUED). 

PAGE 

The  hollow  foot — Varieties  and  treatment — Anterior  metatarsalgia — 
Morton  's  neuralgia — Etiology — Treatment — Achillobursitis — Strain 
of  the  tendo  Achilles — Calcaneobursitis — Plantar  neuralgia — Vaso- 
motor trophic  neuroses — Ervthromelalgia — Dvsbasia  angiosclerotica 
— Intermittent  limp — Hallux  rigidus — Painful  great  toe — Hallux 
varus — Pigeon  toe — Metatarsus  varus — Hallux  valgiis — Hammer  toe 
— Ingrown  toe-nail — Overlapping  toes — Exostoses  of  the  foot — 
Fracture  of  metatarsus — Displacement  of  the  peronei  tendons — 
Shoes,  effects  of  improper  shoes — Demonstration  of  the  proper  shoe 
— Socks    748 

CHAPTEE  XXII. 

DEFORMITIES   OF   THE  FOOT. 

Talipes — Description — Varieties — Statistics  of  talipes,  congenital  and 
acquired — Relative  frequency  of  the  different  varieties — Congenital 
talipes — Etiology — Anatomy — Symptoms — Principles  of  treatment 
of  infantile  club-foot — Treatment — mechanical — by  plaster  band- 
age— by  braces — restoration  of  function — supervision — Treatment 
in  older  subjects — forcible  manual  correction — malleotomy — teno- 
tomy— Wolff's  treatment,  reduction  of  deformity  by  wrenches — 
Phelps'  operation — Operations  on  the  bones — Astragalectomy — 
Osteotomy — Mechanical  treatment — Other  varieties  of  congenital 
talipes  — varus  —  equinus — calcaneus  — valgus — equinovalgus — calca- 
neovalgus — calcaneovarus  —  equiuoeavus  —  valgocavus  —  Congenital 
deformities  of  foot  associated  with  defective  development — with 
absence  of  fibula — with  absence  of  tibia — with  congenital  deficiency 
and  hypertrophy — Constricting  bands — Congenital  oedema — Spina 
bifida  and  talipes 785 

CHAPTER  XXIII. 

DEFORMITIES    OF    THE   FOOT    (CONTINUED). 

Acquired  talipes — Etiology — Diagnosis — Talipes  equinus — Description — 
Etiology — Symptoms — Treatment — mechanical — operative —  Talipes 
calcaneus — Description,  development  of  deformity — Symptoms — 
Treatment  —  mechanical,  operative  —  "Willett  's  operation  —  The 
author 's  operation — Talipes  calcaneovarus  and  calcaneovalgus — 
Talipes  equinovarus  and  talipes  equinovalgus — Talipes  valgus — 
Traumatic  valgus — Other  varieties  of  acquired  talipes — Tendon 
transplantation  in  the  treatment  of  paralytic  talipes — Tendon 
transplantation  and  arthrodesis — Tendon  splicing — Arthrodesis  and 
other  procedures 847 


OETHOPEDIC  SURGERY. 


CHAPTER  I. 

TUBERCULOUS    DISEASE    OF    THE    SPINE. 

Synonym. — Pott's  disease. 

Pott's  disease  is  a  chronic  destructive  process  of  the  bodies 
of  the  vertebrae.  The  spine  bends  at  the  weakened  point,  and 
the  upper  part,  sinking  downvv^ard  and  forward,  throws  into 
relief  one  or  more  of  the  spinous  processes,  thus  an  angular 
posterior  projection  is  formed.  It  is  called  Pott's  disease  be- 
cause such  deformity,  accompanied  by  pain  and  oftentimes  by 
paralysis,  was  first  described  accurately  by  Percival  Pott,  in 
17 Y9.  Angular  deformity  is  simply  the  evidence  of  local  weak- 
ness. Thus  it  might  be  the  result  of  fracture,  or  of  the  erosion 
of  an  aneurism,  or  of  malignant  disease,  or  syphilis,  or  other 
pathological  process ;  but  deformity  from  such  causes  is  not  now 
included  imder  Pott's  disease,  nor  is  the  term  now  synonymous 
with  deformity.  In  the  modern  sense  it  signifies  tuberculous 
disease  of  the  bodies  of  the  vertebrae,  of  which  the  early  symp- 
toms may  be  detected  and  of  which  the  deforming  effects  may 
be  checked  and  even  prevented  by  timely  treatment. 

The  compression  and  collapse  of  the  affected  parts  cause  the 
characteristic  angular  projection  at  the  seat  of  the  disease  (Fig. 
2).  If  one  vertebral  body  is  destroyed  the  projection  will  be 
sharp;  if  several  are  implicated  it  will  be  less  angular,  and  if 
one  side  of  a  body  breaks  down  before  the  other  there  may  be 
lateral  as  well  as  posterior  distortion. 

The  size  of  the  deformity  and  its  effect  upon  the  individual 
depend  in  great  degree  upon  its  situation.  If  the  disease  is 
at  either  extremity  of  the  spine  the  angular  projection  is  slight 
because  the  area  of  the  spine  directly  involved  in  the  deformity 
is  small  compared  to  that  which  is  free  from  disease  (Fig.  5). 
But  if  the  centre  of  the  spine  is  affected  the  opportunity  for 
2  17 


18 


OSTROPEDIC    SUFiGEEY. 


Fig.  1. 


deformity  is  great,  because  the  entire  cohimn  may  enter  into 
the  formation  of  the  angular  kyphosis.  In  such  eases  the  in- 
ternal organs  are  comj)ressed  and  the  effect  upon  the  yital 
mechanism  is  disastrous  (Fig.  23). 

Pott's  disease,  as  contrasted  with  tuberculosis  of  other  bones 
and  joints,  is  peculiar  in  its  inaccessibility;  in  its  proximity  to 
important  parts,  the  yital  organs  in  front 
and  the  sj)inal  cord  behind.  Finally,  in 
that  the  effect^s  of  disease  and  deformity 
influence  in  much  greater  degree  the  entire 
mechanism  of  the  body. 

Pathology. — The  minute  changes  that 
characterize  tuberculosis  of  bone  in  general 
are  described  in  Chapter  V. 

The  first  indication  of  the  disease  is 
usually  found  in  the  anterior  part  of  a 
yertebral  body  just  beneath  the  fibroperi- 
osteal  layer  of  the  anterior  longitudinal 
ligament.  From  this  point  the  granula- 
tion tissue  advances  along  the  front  of  the 
si3ine,..  and  following  the  course  of  the 
bloodyessels  it  invades  the  adjacent  verte- 
bral bodies.  In  other  instances  the  process 
may  begin  in  the  interior  of  a  vertebral 
l3ody,  most  often  in  several  minute  foci 
near  the  upper  or  lower  epiphysis.  These 
coalescing,  gradually  enlarge,  forming  a 
cavity,  surrounded  for  a  time  by  unbroken 
Destruction      of     the   cortical  substance,  which  finally  collapses 

bodies    of    the    first,    sec-  , 

ond  and  third  lumbar  under  the  pressure  01  the  superincumi:»eut 
vertebrse— with   the    re-   ^ei^fit.     Occasiouallv  the  disease  advances 

suiting    deformity.       (Me-    ,        "^      ,       ,  •      \- 

nard.)  beneath  the  anterior  ligament  without  im- 

plicating deeply  the  substance  of  the  bone 
— a  form  of  tuberculous  periostitis,  "  spondylitis  superficialis." 
The  intervertebral  disks  appear  to  offer  some  resistance  to 
the  extension  of  the  disease  from  one  vertebra  to  another,  but 
when  the  bone  is  destroyed  on  either  side  they  quickly  disin- 
tegrate and  disappear.  The  posterior  part  of  the  spinal  column 
usually  remains  free  from  disease,  with  the  exception  of  the 
pedicles  and  articulations  that  may  be  in  direct  contact  with  it. 
In  rare  instances  the  process  may. begin  in  a  lamina  or  spinous 


TUBERCULOUS    DISEASE    OF    THE    SPINE. 


19 


process,  or  in  one  of  the  small  joints;  but  snch  forms  of  local 
tuberculosis  could  bardly  be  classed  as  Pott's  disease. 

The  course  and  outcome  of  the  disease  depend  upon  its  type. 
In  one  instance  the  area  of  primary  infection  is  small  and  the 
local  resistance  is  sufficient  to  check  its  further  progress,  so  that 

Fig.  2. 


Pott" s  disease. 


cure  without  deformity  may  follow.  In  another  the  disease 
is  inactive  and  the  granulation  tissue  undergoes  a  fibroid  trans- 
formation or  becomes  ossified.  In  such  cases  deformity  may 
appear  and  slowly  increase,  practically  without  sjanptoms.  In 
most  instances,  however,  the  infected  granulations  advance  more 


20  OBTHOFEDIC   SUBGEBY. 

rapidly,  destroying  the  bone  or  other  tissue  with  which  they 
come  into  contact.  There  is  the  usnal  retrograde  metamorphosis 
to  cheesy  degeneration,  and  very  frequently  liquefaction  and 
abscess  formation  follow. 

In  cases  of  moderate  severity  that  come  to  autopsy  during 
the  progressive  stage  of  the  disease,  one  finds,  usually,  on  divid- 
ing the  thickened  tissues  in  front  of  the  spine,  a  cavity  the 
walls  of  which  are  lined  with  granulation  tissue  in  various 
stages  of  degeneration,  and  containing  puriform  fluid.  The 
adjoining  vertebral  bodies  present  a  worm-eaten  appearance, 
and  one  or  more  of  them  is  partially  destroyed.  Small  frag- 
ments of  necrosed  bone,  "bone  sand,"  may  be  recognized,  and 
occasionally  sequestra  of  considerable  size  are  present. 

If  the  disease  begins  in  the  interior  of  a  vertebral  body  it  may 
extend  backward  as  well  as  forward,  and  forcing  its  way  into 
the  vertebral  canal  it  may  involve  the  coverings  of  the  spinal 
cord  and  cause  pressure  paralysis  even  before  the  deformity 
attracts  attention.  Less  often  pressure  on  the  cord  may  be  due 
to  the  presence  of  an  abscess  or  to  a  projecting  fragment  of  bone. 
The  calibre  of  the  spinal  canal  may  be  constricted  somewhat  by 
pressure  incidental  to  progressive  deformity  upon  the  softened 
and  thickened  tissues  at  the  seat  of  disease;  but  as  a  rule,  its 
capacity  is  not  directly  lessened  by  the  angular  distortion,  nor 
does  the  degree  of  deformity  directly  influence  the  frequency  of 
paralysis. 

Although  the  disease  may  begin  in  multiple  primary  foci  of 
infection  over  an  extended  area,  or  in  two  or  more  distinct  re- 
gions of  the  spine  simultaneously,  yet  clinical  observation  indi- 
cates that  it  is,  in  most  instances,  originally  confined  to  one 
or  two  adjacent  bodies.  Erom  this  central  point  it  may  extend 
indefinitely  in  either  direction,  but  in  ordinary  cases  the  final 
area  of  deformity  and  rigidity  shows  that  from  three  to  six 
bodies  are  more  or  less  involved  before  cure  is  established. 

If  the  disease  is  limited  in  extent,  the  eroded  surfaces  of  the 
adjoining  vertebrae  may  come  into  direct  contact;  but  if  several 
vertebral  bodies  have  been  destroyed,  the  upper  portion  of  the 
spine  as  it  sinks  downward  is  often  displaced  backward,  so  that 
the  anterior  part  of  one  or  more  of  the  upper  segments  may 
be  apposed  to  the  superior  surface  of  the  first  body  of  the  lower 
section  (Fig,  3).  Less  often  there  may  be  forward  displace- 
ment of  the  upper  part  upon  the  lower  (Fig.  1). 


TUBEBCULOUS    DISEASE    OF    TEE    SPINE. 


21 


At  all  stages  of  the  disease  resistance  to  its  progress  is  evident 
in  the  affected  parts. 
-y    Repair   is   accomplished   occasionally  by   contact    and   solid 
nnion  of  the  adjoining  surfaces  qi  softened  bone ;  but  usually 


Fig.  3. 


Fig.  4. 


Destruction  of  the  bodies  of  the' 
third,  fourth,  fifth,  sixth,  and  seventh 
dorsal  vertebrae  ;  partial  destruction  of 
three   others.       (Menard.) 


The  deformity  corrected,  showing 
the  area  of  the  destructive  process. 
(Menard.) 


the  anchylosis  is  in  part  fibrous,  in  part  cartilaginous,  and  in 
part  bony,  and  this  union  may  be  further  strengthened  by  a 
callous  formation  from  the  thickened  tissues  about  the  seat  of 
the  disease.  In  many  instances  the  articular  processes,  the 
pedicles,  and  laminae  become  anchylosed  before  repair  has  ad- 
vanced appreciably  in  the  anterior  portion  of  the  column. 


22  OETHOPEDIC    SUBGEBY. 

Cure  may  be  absolute,  as  when  no  vestige  of  the  disease 
remains;  it  mav  be  practically  assured,  as  when  the  diseased 
products  undergo  calcareous  degeneration  and  are  shut  in  by 
a  layer  of  solid  bone.  In  other  instances  the  disease  becomes 
quiescent  or  but  slowly  advances,  showing  its  presence  by  ex- 
acerbations of  pain  or  by  the  formation  of  an  abscess  long  after 
active  symptoms  have  ceased. 

Etiology. — The  etiology  of  tuberculosis  of  the  spine  does  not 
differ  from  that  of  tuberculosis  of  other  bones;  the  subject  is 
considered  in  Chapter  V. 

Relative  Frequency.- — Tuberculosis  of  the  spinal  column  is 
more  common  than  of  any  other  single  bone  or  joint,  as  might 
be  expected  from  its  greater  area..  This  is  illustrated  by  the 
statistics  of  tuberculous  disease  treated  in  the  out-patient  depart- 
ment of  the  Hospital  for  Ruptured  and  Crippled  during  a 
period  of  twenty  years,  1885-1904. 

Tuberculosis  of  the  spine 4299  cases. 

Tuberculosis   of    the    hip 3329  cases. 

Tuberculosis  of  other  joints   inclusive 3222  cases. 

Total   10,850 

Also  by  statistics  of  the  Boston  Children's  Hospital  for  a 
similar  period,  1869-1888: 

Tuberculosis  of  the   spine 1864  cases. 

Tuberculosis  of   the  hip,  knee,   ankle,  shoulder,   elbow, 

and  wrist   combined 1856  cases. 

Total 3720 

Of  1996  autopsies  on  subjects  with  tuberculous  disease  of 
bones  and  joints  the  spine  was  involved  in  702 — 35.2  per  cent.^ 

Age. — Pott's  disease,  although  far  more  frequent  in  the  mid- 
dle period  of  childhood,  from  the  third  to  the  tenth  year,  may 
appear  in  earliest  infancy  or  extreme  age. 

In  a  series  of  1259  consecutive  cases  of  tuberculosis  of  the 
spine  collected  from  the  records  of  the  out-door  department 
of  the  Hospital  for  Ruptured  and  Crippled,  analyzed  by  Drs. 
R.  T.  Frank  and  C.  Gunter,  the  ages  of  the  patients  at  the  sup- 
posed time  of  onset  of  the  disease  appeared  to  be  as  follows : 

Less  than  1  year 38  =    3.1  per  cent. 

Between     1  and     2  years 176  ^  14.2  per  cent. 

Between     3  and     5  years 627  =  50.2  per  cent. 

Between     6  and  10  years 234  =  18.3  per  cent. 

Between  11  and  20  years 89  =    7.2  per  cent. 

Between  21  and  30  years 43  =    3.5  per  cent. 

Between  31  and  50  years 31  ^    2.6  per  cent. 

Over  50  years 11  =    0.8  per  cent. 

'  Billroth-Menzel,  Handb.  der  Orthop.  Chir.,  Joachimsthal,  S.  1304. 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  23 

The  voimgest  patient  was  two  months  old,  the  oldest  seventj- 
one  years. 

Thorndike,^  from  the  records  of  the  Boston  Children's  Hos- 
pital for  thirteen  years,  1883  to  1896,  collected  115  cases  of 
tuberculosis  of  the  spine  in  children  of  two  years  or  less.  Seven 
of  these  were  less  than  six  months,  and  twenty  were  under  one 
year  in  age. 

Howard  Marsh^  has  called  attention  to  Pott's  disease  in  the 
aged,  and  cites  three  cases  in  subjects  of  sixty  or  more  years  of 

age- 
Sex, — Sex  exercises  comparatively  little  influence  on  the  lia- 
bility to  disease  of  this  region.  Of  3797  cases  collected  by  Mohr, 
Gibney,  Fischer,  Taylor,  and  Bradford  and  Lovett,  quoted  by 
Hoffa,  2045  were  in  males  and  1752  were  in  females.  Of  1367 
cases  collected  by  Frank  and  Grunter,  708  (52  per  cent.)  were 
in  males  and  659  (48  per  cent.)  were  in  females;  and  in  2455 
cases  tabulated  by  Knight,  1329  were  in  males  and  1126  in 
females.  Of  these  combined  cases  from  the  Hospital  for  Rup- 
tured and  Crippled,  3822  in  number,  53.2  per  cent,  were  in 
males  and  46.8  per  cent,  in  females.-. 

The  Situation  of  the  Disease. — The  dorsolumbar  section  of 
the  spine  is  most  often  affected.  Cervical  disease  is  compara- 
tively infrequent. 

In  the  series  of  1355  cases  from  the  records  of  the  Hospital 
for  Ruptured  and  Crippled,  the  attempt  was  made  to  locate 
the  origin  of  the  disease  by  the  most  prominent  spinous  process 
in  the  tracing.     The  following  are  the  conclusions : 


Cervical. 

Dorsal. 

Lumbar. 

Lumbosacral 

First    

3 

26 

94 

13 

Second    

3 

43 

96 

Third    

15 

42 

64 

Fourth        

20 

48 
49 

57 
6 

Fifth    

13 

Sixth 

22 

76 

Seventh    

24 

82 

Eighth    

97 

Xinth    

92 
110 

Tenth    

Eleventh     

71 

Twelfth    

120 

100 

854 

317 

1 

3 

No    deformity,    cervical 2 

No  deformity  dorsal 31 

No  deformity,  lumbar 22 

55 

Disease  in  two  regions  of  the  spine 16 

Transactions  American  Orthopedic  Association,  1896,  vol.  ix. 
'  Ibid.,  1891,  vol.  iv. 


24  OBTEOPEDIC   SUBGEB¥. 

Similar  statistics  are  recorded  by  DoUinger,^  of  Budapest, 
of  700  cases  of  Pott's  disease.  Of  these  the  situation  of  the  pri- 
mary disease  could  be  ascertained  in  538.  In  63  the  disease 
was  of  the  cervical,  in  321  of  the  dorsal,  and  in  154  of  the 
lumbar  region. 

The  relative  frequency  of  disease  of  the  different  dorsal  and 
lumbar  vertebrae  was  as  follows : 

Dorsal.  Lumbar. 

First    6  59 

Second    7  37 

Third    12  31 

Fourth    10  17 

Fifth    19  10 

Sixth    17 

Seventh    33 

Eighth    36 

Ninth    36 

Tenth   43 

Eleventh    38 

Twelfth    64 

32i  154 

Of  694  autopsies  on  subjects  with  tuberculosis  of  the  spine. 

The  Cervical  region  was  involved  in  185 26.5  per  cent. 

The   Dorsal  region   was  involved   in   310 44.6  per  cent. 

The  Lumlsar  region  was  involved  in  265 44.3  per  cent.- 

The  proportionate  length  of  the  different  sections  of  the  spine 
at  the  age  of  five  years  is,  according  to  Disse  :^ 

Cervical 20.2 

Dorsal    45.6 

Lnnibar   34.2 

looTo 

It  apj)ears  therefore  that  the  frequency  of  the  disease  in  the 
different  regions  of  the  spine  does  not  correspond  to  the  area, 
as  has  been  suggested,  but  that  it  is  proportionately  much  less 
common  in  the  cervical  and  much  more  common  in  the  dorsal 
region. 

Dollinger  Frank  and  Guiiter.  Area. 

Cervical 11.7  per  cent.      Cervical    7.7  per  cent. — 20.2 

Dorsal   59.6  per  cent.      Dorsal    66.4  per  cent. — -45.6 

Lumbar 28.6  per  cent.      Lumbar   25.6  per  cent. — 34.2 

This  may  be  explained  apparently  by  the  greater  strain  to 
Avhich  the  middle  and  lower  parts  of  the  spine  are  subjected,  as 

^  Die  Behandlung  der   Tnberculosen  Wirbelentzundung,   Stuttgart,   1898. 
"  Billroth-Menzel,  Locus  cit. 
=  Skeletlehre,  1896. 


TUBEECULOUS    DISEASE    OF    TEE    SPINE.  25 

Avell  as  by  the  relative  proportion  of  cancellous  tissue  which 
offers  the  opportunity  for  infection. 

It  may  be  noted  in  this  connection  that  the  proportionate 
length  of  the  sections  of  the  spine  changes  somewhat  with  the 
age,  as  is  illustrated  by  the  following  table,  the  scale  being 
1000.1 

Cervical.  Thoracic.  Lumbar. 

At  birth  240  490  260 

.   Three  years 214  479  306 

Five  years 206  486  308 

Eleven  years  209  500  290 

Fourteen  years 216  500  284 

Adnlt    195  482  323 

Prognosis. — The  prognosis  in  tuberculous  disease  is  discussed 
in  Chapter  V.  Pott's  disease  is  the  most  dangerous  of  the 
tuberculous  affections  of  the  bones  or  joints,  because  of  the 
relative  importance  of  the  structure  affected  and  of  the  parts 
lying  in  contact  with  it. 

It  is  evident  also  that  the  degree  of  deformity  and  its  situa- 
tion have  a  direct  influence  on  the  prognosis.  In  disease  of 
either  extremity  of  the  spine  the  direct  deformity  is  insignifi- 
cant and  the  secondary  effect  upon  the  trunk  is  slight. 

In  the  typical  "hump-back"  deformity,  however,  the  con- 
tents of  the  thorax  and  abdomen  are  compressed;  the  blood- 
vessels are  distorted,  and  the  calibre  of  the  aorta,  which  is  more 
directly  affected,  is  often  much  diminished ;  respiration  is  made 
difficult,  and  the  circulation  is  impeded ;  as  a  consequence,  the 
heart  is  usually  hypertrophied  and  valvular  insufficiency  is  not 
infrequent.  Thus  the  vital  functions,  which  are  carried  on  at 
a  disadvantage  at  all  times  may  be  overtaxed  by  the  strain  of 
unfavorable  surroundings,  overwork,  or  disease.  It  is  a  matter 
of  common  observation  that  few  of  those  who  are  markedly  de- 
formed reach  old  age.  On  the  other  hand,  it  may  be  assumed 
that  slight  deformities,  or  those  which  do  not  as  directly  inter- 
fere with  the  vital  functions,  exercise  but  little  influence  upon 
the  future  well-being  of  the  patient. 

■  Although  the  absolute  mortality  of  Pott's  disease  cannot  be 
accurately  estimated,  it  may  be  stated  that  at  least  20  per  cent, 
of  all  patients  die  during  the  progTcss  of  the  disease  and  within 
a  few  years  after  its  onset,  from  causes  directly  or  indirectly 
dependent  upon  the  local  lesion.  Some  of  these  die  from  gen- 
eral dissemination  of  the  tuberculous  infection  and  tuberculous 

^  Moser,  Hanclb.  der  Orth.  Chir.  Joaehimsthal,  1905,  p.  521. 


26  ORTHOPEDIC    SUBGEBY. 

meningitis;  some  from  exhaustion  following  septic  infection 
and  persistent  suppuration,  or  from  amyloid  degeneration  of 
the  internal  organs;  some  from  tuberculosis  of  the  lungs,  and 
many  from  intercurrent  affections  that  are  fatal  because  of  the 
devitalizing  influence  of  the  disease  and  its  complications. 

The  prognosis  of  Pott's  disease  in  the  individual  case  is  in- 
fluenced by  many  considerations.  In  one  instance  the  family 
history  is  good,  the  surroundings  are  favorable,  the  patient  is 
in  good  condition,  and  the  disease  is  localized ;  one  is  then 
inclined  to  look  upon  it  as  an  accident,  and  hardly  considers  the 
possibility  of  a  fatal  termination;  while  in  another  case  the 
weakness  and  undervitalization  of  the  body  are  so  evident  that 
the  affection  of  the  spine  seems  but  an  incident  of  a  general  de- 
generation. 

Symptoms. — The  most  distinctive  sign  of  Pott's  disease  is 
deformity.  At  an  early  stage  of  the  process  there  may  be  but 
a  slight  irregularity  in  the  contour  of  the  spine,  and  if  several 
adjacent  vertebral  bodies  are  affected  the  projection  may  be 
.somewhat  rounded  in  outline;  but  as  compared  with  other  de- 
formities of  the  spine,  that  of  Pott's  disease  is  characteristically 
angular,  and  as  its  cause  is  loss  of  substance,  its  formation  is 
accompanied  by  and  must  have  been  preceded  by  the  symptoms 

•  of  bone  disease. 

Deformity  is  thus  the  evidence  of  a  destructive  process  that 

'  may  have  existed  for  months  and  only  by  its  early  recogiiition 
can  the  ideal  result  be  attained.  The  spine  which,  although 
weak,  is  still  straight  may  be  held  straight ;  but  when  the  de- 
formity is  present,  it  can  be  remedied  only  in  part,  and  it  may 

V  be  difficult  even  to  check  its  progress.  For  as  the  upper  seg- 
ment of  the  spine  sinks  forward  and  downward,  the  influences 
of  compression  and  attrition  increase  the  activity  of  the  local 
process  and  aggravate  its  effects. 

Formerly  angular  deformity  was  thought  to  be  the  essential 
sign  of  Pott's  disease,  and  even  now  the  fact  is  not  generally 
recognized  that  the  detection  of  the  disease  in  its  inception  is 
both  possible  and  easy,  if  one  will  apply  the  same  methods  that 
serve  for  the  diagnosis  of  other  affections  not  attended  by  a 
symptom  so  obvious  as  external  deformity.  It  is  to  such  appli- 
cation of  the  principles  of  differential  diagnosis  that  attention 
is  called. 

The  spine  is  the  chief  support  of  the  body,  possessing  a  free 
mobility  that  accommodates  it  to  every  movement  of  the  body. 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  27 

It  is  evident,  therefore,  that  the  symptoms  of  a  destructive 
disease  must  be  pain,  weakness,  and  impairment  of  normal 
motion.  Motion  and  support  are  not,  however,  the  only  func- 
tions of  the  spine;  it  contains  the  spinal  cord,  from  which 
branch  the. nerves  that  supply  the  organs  and  members  of  the 
body.  Thi^toay  be  implicated  at  an  early  stage  of  the  affec- 
tion and  the  sudden  onset  of  paralysis  may  overshadow  the 
symptoms  of  the  original  disease.  In  other  instances  the  tumor 
of  an  abscess — one  of  the  common  accompaniments  of  tubercu- 
lous disease — may  interfere  with  the  functions  of  important 
,parts  lying  in  the  neighborhood  of  the  spine,  and  peculiar 
symptoms,  due  to  this  cause,  may  attract  attention  before  the 
primary  disease  is  suspected./  Such  symptoms  may  be  mislead- 
ing and  it  is  well,  therefore,  to  consider  them  apart  from  those 
that  indicate  the  primary  effect  of  the  disease  upon  the  spine. 
These  direct  symptoms  usually  precede  and  always  accompany 
the  secondary  or  complicating  symptoms,  and  upon  them  the 
diagnosis  depends. 

The  primary  and  diagnostic  symptoms  of  Pott's  disease  may 
be  classified  as  follows : 

(a)   Pain. 

(6)    Stiffness. 

(c)  Weakness. 

(d)  Awkwardness. 
■  (e)   Deformity. 

(a)  Pain, — At  first  thought,  one  might  expect  the  pain  of 
Pott's  disease  to  be  localized  at  the  affected  vertebrae,  and  to  be 
accompanied  by  sensitiveness  to  pressure  or  even  by  infiltration 
and  swelling  of  the  neighboring  tissues ;  but  it  will  be  remem- 
bered that  the  bodies  of  the  vertebrae  are  in  the  interior  of  the 
trunk,  practically  speaking,  as  near  to  its  anterior  as  to  its 
posterior  surface  (Fig.  9),  and  that  the  products  of  the  disease 
pass  downward  and  forward,  rarely  backward.  Thus  sensitive- 
ness to  pressure  on  the  projecting  spinous  processes  is  unusual, 
and  palpation,  except  in  the  cervical  region,  is  of  comparatively 
little  diagnostic  value. 

The  pain  of  Pott's  disease  is  not  localized  in  the  neighbor- 
hood of  the  disease,  because  the  filaments  that  supply  the 
bodies  of  the  vertebrae  are  insignificant  parts  of  nerves  that 
are  distributed  to  distant  points — to  the  head,  to  the  limbs,  to 
the  front  and  sides  of  the  trunk — and  to  these  parts  the  pain  is 
referred :   thus   "  ear-ache  "   or   "  stomach-ache  "  or   "  sciatica  " 


28  OETEOPEDIC   SUBGEB¥. 

may  be  symptomatic  of  Pott's  disease.  The  pain  is  by  no  means 
constant;  it  is  induced  by  jars  or  by  sudden  or  unguarded 
movements.  It  is  often  worse  at  night,  when,  after  the  relaxa- 
tion of  the  muscular  tension  that  has  protected  the  part,  the 
unconscious  movements  during  sleep  cause  discomfort,  and  the 
child  moans  in  its  sleep,  or  is  restless,  and  sometimes  it  wakes 
with  a  cry — "night  cry." 

(&)  Impairment  of  Function  or  Loss  of  Normal  Mobility:  Stiff- 
ness.— Stiffness  is  in  part  voluntary,  in  the  sense  that  the  patient 
adapts  his  movements  and  attitudes  to  the  sensitive  spine,  but 
the  essential  stiffness  of  Pott's  disease  is  caused  by  the  involun- 
tary muscular  tension  and  contraction  of  the  muscles.  This 
reflex  muscular  spasm  varies  in  degree,  according  to  the  state 
of  the  imderlying  disease.  It  may  fix  the  spine  or  it  may  check 
only  the  extremes  of  motion,  but  it  is  always  present,  preceding 
deformity  and  accompanying  it  until  cure  is  established;  thus 
it  is  the  most  important  of  the  diagnostic  symptoms  of  Pott's 
disease. 

(c)  Weakness. — As  the  disease  affects  the  most  important 
support  of  the  body,  it  is  a  direct  as  well  as  an  indirect  cause 
of  weakness,  and  the  more  vulnerable  the  spine  the  more  pro- 
nounced is  this  symj)tom ;  thus  in  a  young  child,  "  loss  of  walk," 
the  refusal  to  stand,  and  the  instinctive  desire  for  support,  are 
the  symptoms  that  first  call  attention  to  the  local  disease. 

(d)  Change  in  Attitude:  Awkwardness. — This  really  sums  up 
the  effects  of  the  preceding  symptoms,  since  it  is  evident  that 
pain,  weakness,  and  stiffness  must  cause  a  change  in  appearance 
and  in  the  habitual  attitudes  of  the  patient.  Such  symptomatic 
attitudes  may  be  almost  diagnostic  of  the  disease  and  of  the 
part  of  the  spine  involved. 

\  if)  Change  in  the  Contour  of  the  Spine:  Deformity. — The  de- 
formities of  Pott'^  disease  may  be  classified  as : 

1.  Bone  deformity. 

2.  Muscular  deformity. 

3.  Compensatory  deformity. 

The  characteristic  angular  projection  caused  by  destruction 
of  bone  has  been  described  already. 

Muscular  deformity  is  the  distortion  due  to  muscular  spasm 
or  contraction.  Of  this,  the  wryneck,  symptomatic  of  cervical 
disease,  and  psoas  contraction  in  the  lower  region  of  the  spine, 
are  the  most  familiar  examples. 

Compensatory  deformity  signifies  the  more  general  effect  of 


TUBERCULOUS    DISEASE    OF    THE    SPINE. 


29 


Fig.  5. 


the  local  disease  and  local  distortion  upon  the  spine  as  a  whole 
(Fig.  5).  Thus  an  angular  projection  must  be  balanced  by  a 
compensatory  incurvation,  and  lateral  distortion  in  one  direc- 
tion by  lateral  distortion  in  another. 

These  three  deformities  are,  of  course,  nearly  related,  and 
they  are  usually  combined,  although  muscular  distortion  may 
jDrecede  the  stage  of  bone  destruction, 
while  the  compensatory  changes  are  not 
immediately  apparent.  On  the  other 
hand,  the  secondary  changes  in  the  con- 
tour of  the  spine  may  catch  the  eye 
before  the  primary  local  deformity  is 
detected. 

Lateral  deviation  of  the  spine  is  not 
infrequent ;  it  may  be  a  direct  distor- 
tion at  the  seat  of  the  disease,  caused  by 
the  destruction  of  the  side  of  a  vertebral 
body  (Fig.  22),  but  more  often  it  is  a 
secondary  effect  of  such  irregular  ero- 
sion at  one  or  the  other  extremity  of 
the  spine,  or  the  effect  of  muscular  con- 
traction, or  it  may  be  due  to  simple 
weakness,  in  which  case  it  is  a  transient 
symptom. 

Finally,  even  in  incipient  cases, 
there  is  almost  always  a  slight  change 
in  the  outline  of  the  spine  due  to  local 
rigidity;  the  spine  no  longer  forms 
a  long,  regular  curve  when  the  body 
is  bent  forward,  but  the  outline  is  bro- 
ken at  or  near  the  seat  of  the  disease 
(Fig.  7). 

Secondary  or  Complicating  Symptoms,  (a)  Abscess., — This 
™^7?  by  its  size  or  situation,  cause  peculiar  symptoms.  In  the 
retropharyngeal  space  it  may  interfere  with  a  respiration  and 
deglutition.  In  the  thoracic  region  it  might  be  mistaken  for 
pleurisy  or  empyema,  and  when  it  forms  a  tumor  in  the  iliac 
fossa  it  may  interfere  with  locomotion. 

(b)  Paralysis,- — This  is  usually  a  late  symptom,  but  if  the 
disease  begins  in  the  centre  or  posterior  part  of  a  vertebral  body 
it  may  implicate  the  spinal  cord  before  deformity  is  apparent. 

Abscess  and  paralysis  are  symptoms  that  may  be  explained 


A,  direct  deformity;  B. 
compensatory  deformity. 
The  dotted  line  indicates 
tlie  normal  contour  of  the 
spine. 


30 


ORTHOPEDIC    SUEGEBY. 


by  Pott's  disease,  but  other  than  by  calling  attention  to  disease 
of  the  spine  as  a  j)ossible  cause  of  the  complication,  they  do  not 
aid  one  in  determining  the  diag-nosis ;  for  this  reason  they  are 
classed  as  secondary  symptoms. 

General  Symptoms.- — Especial  stress  is  laid  by  certain  writers 
^^ipon  the  diagnostic  value  of  a  slight  but  constant  elevation  of 
the^temperature.  This  is  usually  present  if  the  disease  is  active 
or  when  an  abscess  is  approaching  the  surface,  but  the  positive 
value  of  the  symptom  in  early  or  quiescent  cases  is  doubtful. 
It  may  be  assumed  also  that  a  patient  suffering  from  tubercu- 
lous disease  of  the  sj^ine  will  present  some  evidence  of  a  painful 
and  depressing  affection,  or  of  inherited  or  acquired  weakness; 
yet  it  must  be  remembered  that  the  absence  of  such  general 
symptoms  would  not  exclude  Pott's  disease. 

Fig.  6. 


Normal  contour  and  flexibility  of  the  spine. 


The  Contour  and  Flexibility  of  the  Spine. — In  the  enumeration 
of  the  early  symptoms  of  Pott's  disease,  two  have  been  noted 
as  of  especial  importance- — the  impairment  of  normal  mobility 
and  the  eifect  of  the  disease  upon  the  contour  of  the  spine  and 
upon  the  attitudes  of  the  patient.  Therefore,  in  the  study  of 
normal  spine  the  standard  with  which  that  suspected  of  disease 
must  be  compared,  mobility  and  contour,  at  different  ages  and 
under  different  conditions  should  receive  especial  consideration. 

The  sj^ine  as  a  whole  is  a  flexible  column  presenting  certain 
constant  curves,  forward  in  the  upper,  backward  in  the  middle, 


TUBEECULOUS    DISEASE    OF    THE    SPINE. 


31 


and  forward  again  in  tbe  lower  region.  These  curves  are  "essen- 
tially the  effect  of  the  force  of  gravity  and  of  the  action  of  the 
muscles  in  balancing  the  weight  of  the  body  in  the  upright  atti- 
tude. In  the  adult  they  are  practically  fixed ;  in  early  childhood 
they  can  be  nearly  obliterated  by  traction  in  the  horizontal  posi- 
tion ;  and  in  infancy  they  do  not  exist.  If  the  newborn  infant 
is  placed  in  a  sitting  posture  the  head  falls  forward  and  the 
spine  bends  in  one  long  backward  curve,  characteristic  of  weak- 
ness.    If  when  it  lies  on  the  back  the  legs  are  drawn  down 


Fig 


Incipient    Potfs    disease.      Showing   the   brealj   in   the   contour    of   the   spine,    of 
which   the   normal    flexibility   is   but    slightly    impaired. 


from  their  habitual  attitude  of  semiflexion,  it  will  be  noticed 
that  the  range  of  extension  is  somewhat  limited  because  of  the 
absence  of  the  lumbar  curve  and  the  inclination  of  the  pelvis. 
When  the  gain  in  muscular  power  is  sufficient  to  enable  the  in- 
fant to  raise  and  to  control  the  head,  the  curve  of  the  neck  ap- 
pears. Later,  when  the  child  stands,  the  erector  spinas  muscles 
hold  the  body  upright  against  the  resistance  of  the  iliopsoas 


32 


OBTHOPEDIC    SUBGEBY 


Fig.  8. 


group  and  of  the  ligaments  of  the  hip-joints;  thus  the  lumbar 
curve  and  the  inclination  of  the  pelvis  result,  and  the  normal 
contour  of  the  spine  is  established. 

If  from  the  odontoid  process  of  the  axis  of  a  normal  indi- 
vidual in  the  erect  posture  a  line  be  dropped  to  the  ground,  this 

perpendicular  or  v^^eight  line,  about 
which  the  weight  of  the  body  is  bal- 
anced, will  indicate  the  curves  of  the 
spine,  and  divide  it  into  sections  that 
correspond  sufficiently  well  to  function. 
The  cervical  curve  ends  at  the  second 
dorsal  vertebra,  the  thoracic  curve  at 
the  twelfth  dorsal,  and  the  lumbar  curve 
at  the  sacrovertebral  angle  (Fig.  8). 

What  has  been  spoken  of  as  the  nor- 
mal contour  of  the  spine  varies  consid- 
erably in  the  adult.  It  is  affected  by 
the  occupation  and  by  many  other  cir- 
cumstances ;  of  this,  the  round  shoulders 
of  the  cobbler  or  the  weaver,  the  stoop 
of  weakness,  of  old  age,  and  the  like 
are  familiar  examples;  but  in  child- 
hood distinct  variations  from  the  nor- 
mal contour  almost  always  have  a 
clearly  defined  pathological  cause.  As 
the  normal  contour  is  the  effect  of  the 
balancing  of  the  body  in  the  upright 
posture,  it  is  evident  that  if  the  outline  of  one  part  is  perma- 
nently changed  compensation  for  this  change  must  be  made  in 
another  part.  Thus  when  deformity  is  well-marked,  the  normal 
curves  of  the  spine  are  often  completely  reversed  (Fig.  5),  and 
even  in  early  cases  the  abnormal  contour  may  attract  attention, 
before  local  deformity  is  noticeable. 

Divisions  of  the  Spine. — Although  the  spine  is  a  flexible  column 
whose  outline  changes  with  every  movement  and  posture  yet  the 
range  and  character  of  this  motion  vary  greatly  in  different 
parts.  In  the  cervical  and  lumbar  regions  the  range  is  exten- 
sive, because  of  the  relatively  large  proportion  of  elastic  inter- 
vertebral substance,  because  of  the  direction  of  the  articular 
surfaces,  and  because  the  spine  is  near  the  centre  of  the  body. 
Motion  is  very  limited  in  the  thoracic  region,  because  the  inter- 


The  divisions  of  the  spine. 


TUBEBCULOUS    DISEASE    OF    THE    SPINE. 


33 


vertebral  disks  are  thin,   because  of  the   overlapping  spinous 
processes,    and  because  it  forms   a  part   of  the   rigid  thorax. 


Fig.  9. 


Cross-section  of  the  body  of  a  child  at  the  third  dorsal  vertebra.      (Dwight.) 


Where  free  motion  is  essential  to  the  habitual  attitudes,  inter- 
ference with  normal  motion,  and  the  other  attendant  symptoms 
3 


34  ORTHOPEDIC   SUEGEBY. 

of  disease  will  be  apparent  earliest.  Thus  one  more  often  has 
the  opportunity  for  early  diagnosis  in  disease  of  the  lumbar  and 
cervical  regions  because  in  the  one  the  motions  necessary  in 
stooping,  sitting,  and  standing  are  constrained,  and  in  the  other 
the  neck  is  stiff,  or  the  head  is  turned  or  drawn  from  the  normal 
line.  In  the  thoracic  region  early  diagnosis  is  less  often  made, 
because  in  this  section  motion  is  so  unimportant  that  its  re- 
straint may  escape  the  attention  of  the  patient  or  parent.  In 
considering  diagnosis,  therefore,  and,  in  fact,  treatment  and 
prognosis,  one  should  divide  the  spine  into  three  sections  to 
correspond  with  function : 

1.  The  neck  part,  that  permits  free  motion  of  the  head,  end- 
ing at  the  third  dorsal  vertebra. 

2.  The  rigid  thoracic  part,  which  includes  the  third  and  the 
tenth  dorsal  vertebrae. 

3.  The  lower  part,  made  up  of  the  two  lower  dorsal  and  the 
lumbar  vertebrae,  in  which  the  principal  movements  of  the  trunk 
are  carried  out  (Fig.  8). 

One  must  bear  in  mind  the  distribution  of  the  nerves,  because 
the  characteristic  pain  is  referred  to  their  terminations,  also, 
the  parts  in  relation  to  the  spine  at  different  levels  that  may  be 
implicated  in  the  disease.  Thus  remembering  that  the  symp- 
toms of  Pott's  disease  are  in  general,  stiffness,  weakness,  pain 
and  deformity,  one  will  always  apply  these  symptoms  to  a  par- 
ticular region  of  the  spine,  and  will  picture  to  himself  the  effect 
of  such  stiffness,  weakness,  and  deformity  at  this  or  that  verte- 
bra; the  effect  of  an  abscess  in  this  or  that  situation,  and  the 
area  of  paralysis  that  might  be  caused  by  pressure  on  the  cord 
at  one  or  another  level. 

Landmarks. — ^The  atlas  is  on  a  line  with  the  hard  palate. 

The  axis  is  on  a  line  with  the  free  edge  of  the  upper  teeth. 

The  transverse  process  of  the  atlas  is  just  below  and  in  front 
of  the  tip  of  the  mastoid  process. 

The  hyoid  bone  is  opposite  the  fourth  cervical  vertebra. 

The  cricoid  cartilage  is  on  a  line  with  the  sixth  cervical  ver- 
tebra. 

The  upper  margin  of  the  sternum  is  opposite  the  disk  between 
the  second  and  third  _dorsal  vertebrae.  The  junction  of  the  first 
and  second  sections.jC^ -the  sternum  is  opposite  the  fourth  dorsal 
vertebra.  '^-' 

The  tip  of  the  ensiform  cartilage  is  opposite  the  lower  part  of 
the  body  of  the  tenth  dorsal  vertebra. 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  35 

The  anterior  extremity  of  the  first  rib  is  on  a  line  with  the 
fourth  rib  at  the  spine,  the  second  with  the  sixth,  the  fifth  with 
the  ninth,  and  the  seventh  with  the  eleventh. 

The  scapula  overlaps  the  second  and  the  seventh  ribs,  its 
lower  angle  being  opposite  the  centre  of  the  eighth  dorsal  ver- 
tebra. 

The  root  of  the  spine  of  the  scapula,  the  glenoid  cavity,  and 
the  interval  between  the  second  and  third  dorsal  spines  are  in 
the  same  plane. 

The  most  constant  landmark  from  which  to  count  is  the  spin- 
ous process  of  the  fourth  lumbar  vertebra,  which  is  on  a  line 
with  the  highest  point  of  the  crest  of  the  ilium.  The  umbilicus 
is  near  the  same  plane. 

The  Inclination  of  the  Pelvis.- — In  the  erect  attitude  the  plane 
of  the  brim  forms  an  angle  of  50  degrees  to  60  degrees  with  the 
horizon.^ 

The  tip  of  the  coccyx  is  opposite  the  lower  border  of  the  sym- 
physis pubis. 

Length  of  the  Spinal  Cord. — In  the  adult  the  spinal  cord  ter- 
minates at  the  lower  margin  of  the  first  lumbar  vertebra.  At 
birth  it  extends  to  the  third  lumbar  vertebra  and  its  membranes 
to  the  second  division  of  the  sacrum. 

The  Intervertebral  Disks. — In  the  adult  the  intervertebral  disks 
form  41.9  per  cent,  of  the  cervical,  26.4  per  cent,  of  the  dorsal, 
and  44.6  per  cent,  of' the  lumbar  regions  of  the  spine  (Dwight). 

The  character  of  the  disease,  its  manifestations,  and  its  effects 
upon  the  spine  having  been  outlined,  the  student  is  now  brought, 
as  it  were,  into  actual  contact  with  the  patient  and  his  friends. 
And  as  Pott's  disease  is  the  most  important  of  the  chronic 
affections  of  childhood,  it  will  serve  as  a  type  to  illustrate 
methods  of  examination  and  of  treatment  as  applied  in  ortho- 
pedic practice. 

The  Rational  Signs, — The  symptoms  of  Pott's  disease  vary 
decidedly,  not  only  with  the  region  of  the  spine  involved,  but 
also  with  the  age  and  surroundings  of  the  patient.  Like  other 
forms  of  tuberculous  disease  it  is  an  insidious  chronic  affection, 
and  its  early  symptoms  may  fail  to  attract  attention,  because 
they  are  irregular  or  intermittent.  It  is  often  after  a  fall  or 
violent  play  that  the  evidences  of  pain  or  weakness  can  no 
longer  be  overlooked,  so  that  injury  is  likely  to  occupy  a  promi- 
nent place  in  the  history. 

^Men,  54.17;  Women,  51.72.  Prochvnik  Archiv  f.  gjn.,  19,  1.  1882. 
This  inclination  is  increased  when  the  thighs  are  abducted  to  the  full  limit. 


36  OBTHOPEDIC    SURGERY. 

History.. — The  account  of  the  disease  given  bj  the  parent  is 
usnally  indefinite  and  misleading.  Certain  points,  however,  of 
relative  importance  may  be  ascertained  by  the  following  ques- 
tions : 

One  asks  if  the  immediate  relatives  of  the  child  have  suffered 
from  phthisis  or  other  form  of  tuberculosis,  as  this  might  indi- 
cate a  predisposition  to  disease,  and  thus  affect  the  progTiosis. 

One  asks  if  the  child  has  been  robust  or  the  reverse,  and  if 
recovery  from  the  ordinary  ailments  of  childhood  was  prompt 
or  tedious,  in  order  that  one  may  judge  of  the  quality  of  the 
patient. 

One  next  asks,  not  "how  long  has  the  child  been  ill?"  for 
this  is  usually  understood  to  refer  to  the  duration  of  the  more 
decided  symptoms,  but  "when_jvvas_  the  child  last  perfectly 
well  ? "  One  asks  particularly  as  to  the  onset  of  the  first  sjanp- 
toms  whether  it  was  sharp  and  decided,  or  gradual  and  ill- 
defined;  if  the  symptoms  were  preceded  by  contagious  disease. 
This  latter  is  an  important  question,  because  measles,  for  ex- 
ample, predisposes  to  tuberculous  infection  or  at  least  to  its  local 
outbreak,  and  diphtheria  is  often  followed  by  paralysis  or  by 
weakness  that  may  simulate  certain  symptoms  of  Pott's  disease. 
The  character  of  the  injury  that  almost  every  patient  is  sup- 
posed to  have  received  is  then  investigated.  It  should  be  made 
clear  whether  the  injury  was  the  direct  cause  of  the  symptoms, 
or  if  it  may  have  simply  aggravated  or  brought  to  light  the 
dormant  disease  or  if,  as  is  often  the  case,  there  is  simply  an 
indefinite  remembrance  of  an  injury  which  has  no  connection 
with  the  symptoms. 

To  establish  injury  as  the  direct  cause  of  symptoms,  the 
patient  must  have  been  well  at  the  time  of  the  accident,  the 
symptoms  must  have  followed  immediately  and  must  have 
persisted  since ;  and  finally,  the  symptoms  must  be  of  a  nature 
to  be  explained  by  a  definite  injury. 

By  careful  questioning  one  may  usually  determine  whether 
the  symptoms  of  which  the  patient  complains  are  acute  or 
chronic.  This  is  of  importance  because  tuberculosis  is  a  chronic 
disease — one  of  the  few  chronic  diseases  of  childhood — although 
its  exacerbations  may  resemble  the  symptoms  of  acute  disease 
or  even  injury. 

However  important  a  correct  history  may  be,  it  is  upon  the 
physical  examination  that  the  diagnosis  practically  depends. 


TUBERCULOUS    DISEASE    OF    TRE    SPINE.  37 

Physical  Signs.- — The  phj'sical  examination  begins  with  in- 
s]3ection  when  one  notes  the  general  condition  and  the  actions 
and  postnres  of  the  patient. 

Voluntary  actions  and  attitudes  are  important,  because  they 
show  the  adaptation  of  the  body  to  the  disease,  the  conscious 
and  unconscious  efforts  of  the  patient  to  guard  the  weak  part 
from  strain  and  from  motions  that  caused  discomfort  and  pain. 
Direct  inspection,  palpation,  and  the  tests  of  voluntary  and  pas- 
sive motion  are  of  still  greater  importance,  because  by  such 
means  one  may  demonstrate  the  presence  of  disease  and  localize 
it  with  accuracy. 

The  examination  must  be  purposeful.  When  one  asks  the 
patient  to  pick  up  a  coin  from  the  floor,  it  is  to  test  the  lower 
region  of  the  spine  for  the  symptoms  of  weakness  and  stiffness. 
The  ability  to  perform  the  act  with  ease  by  no  means  excludes 
disease  of  the  spine  in  the  regions  not  especially  involved  in  the 
movements  of  stooping  or  turning  the  body,  although  this  would 
apjDear  to  be  the  general  belief. 

Such  tests  must  not  only  be  purposeful,  but  they  must  be 
adapted  to  the  age  and  intelligence  of  the  patient.  The  child 
that  refuses  to  pick  up  a  coin  will  often  gather  up  its  clothing, 
because  it  wishes  to  be  clothed  again.  If  it  will  not  stoop,  it 
will  rise  usually  if  placed  in  the  recumbent  or  sitting  posture — - 
an  equally  useful  test.  A  child  will  walk  toward  its  mother  if 
placed  at  a  distance  from  her.  It  will  always  turn  its  head 
toward  her;  thus  voluntary  motion  of  the  cervical  region  may 
be  tested  by  changing  the  mother's  position,  while  the  child  is 
held  by  the  examiner.  Young  children-  that  struggle  and  resist 
passive  motion  if  placed  on  the  table,  submit  quietly  when  held 
in  the  mother's  arms. 

Various  simple  and  effective  tests  will  suggest  themselves  to 
the  examiner  who  has  a  definite  purpose  in  view,  but  much 
patience  may  be  required  in  early  cases,  and  several  examina- 
tions may  be  necessary  before  the  presence  or  absence  of  disease 
can  be  definitely  determined.  It  is  important  to  remember 
that  in  childhood  at  least,  abnormal  symptoms  always  have  a 
cause ;  therefore,  a  patient  should  be  kept  under  observation 
until  the  cause  is  discovered. 

Of  all  the  early  signs  of  Pott's  disease  restriction  of  motion 
due  to  reflex  muscular  contraction  is  the  most  important,  since 
it  precedes  deformity  and  accompanies  it  until  cure  is  finally 
established.      This   muscular   resistance    limits   motion    in    all 


38  OBTHOPEDIC    SUBGEEY. 

directions;  thus  it  maj  be  distinguislied  from  the  spasm  or  con- 
traction of  certain  groups  of  muscles  /caused  by  irritation  or 
inflammation  not  connected  with  the  spine,  for  in  such  instances 
inotion  is  limited  only  in  the  directions  directly  opposed  by  the 
muscular  contraction.  True  reflex  muscular  spasm  is  quite 
independent  of  the  will,  and  thus  it  may  be  distinguished  from 
simple  voluntary  resistance  on  the  part  of  the  patient. 

The  muscular  resistance  is  most  marked  in  the  neighborhood 
of  the  disease,  but  it  extends  to  a  greater  or  less  distance  accord- 
ing to  the  acuteness  of  the  local  process  and  the  susceptibility 
of  the  patient./ 

Even  in  early  cases  the  situation  of  the  disease  is  usually 
shown  by  a  slight  irregularity  of  the  spine  in  the  centre  of  the 
area  made  rigid  by  muscular  spasm,  as  well  as  by  the  change  of 
contour.  This  change  in  outline  and  in  flexibility  may  be 
demonstrated  by  bending  the  patient  forward.  If  the  spine 
forms  a  long,  even,  regular  curve,  and  if  there  is  no  evidence  of 
pain  or  stiffness  when  such  an  attitude  is  assumed,  Pott's 
disease  is  extremely  improbable.  If,  on  the  other  hand,  the 
outline  of  the  curve  is  broken;  if  the  motion  of  one  section  of 
the  spine  is  restrained,  disease  may  be  suspected;  and  if  other 
evidence  of  tuberculous  ostitis  is  present,  the  diagiiosis  may  be 
made  with  certainty  (Figs.  6  and  7). 

By  a  careful  physical  examination  one  may  expect  to  detect 
Pott's  disease  at  its  inception  and  to  fix  upon  its  location,  or  at 
least  upon  the  point  suspected  of  disease.  One  will  then  ask 
one's  self  if  tuberculous  disease  of  the  bodies  of  the  vertebras  of 
this  particular  region  will  satisfactorily  explain  all  the  symp- 
toms; if,  for  example,  the  pain  corresponds  to  the  distribution 
of  the  nerves ;  if  restraint  of  function  will  explain  the  attitudes 
of  the  patient,  and  if  the  change  in  contour  is  significant  of  a 
destructive  process. 

As  has  been  stated  the  symptoms  and  the  effects  of  the  disease 
differ  according  to  the  function  of  the  part  of  the  spine  involved, 
and  the  further  examination  should  be  conducted,  therefore, 
from  this  standpoint. 

1.  Regional  Examination:  the  Lower  Region. — Considering 
the  regions  of  the  spine  in  the  order  of  liability  to  disease  one 
begins  with  the  lower  section,  comprising  the  lumbar  and  the 
two  lower  dorsal  vertebras,  that  more  nearly  correspond  in  shape 
and  function  to  the  lumbar  than  to  the  thoracic  division. 


TUBEBCULOUS   DISEASE    OF    THE    SPINE. 


39 


This  is  the  region .  of  free  and  extensive  motion ;  thus  the 
painful  stiffness,  characteristic  of  the  disease,  is  usually  evident 
long  before  the  stage  of  bone  destruction. 

The  characteristic  attitude  of  the  patient  is  one  of  what  might 
be  called  overerectness,  and  in  many  instances  there  is  an  in- 
creased holloivness  of  the  back   (lordosis,  Figs.   10   and  12)  ; 


Fig.  10. 


Fig.  11. 


Disease  of  the  upper  lumbar  region 
before  the  stage  of  deformity,  show- 
ing abnormal  lordosis. 


The  same  patient    (Fig.   10)    five  years 
later,  showing  deformity. 


thus  the  prominent  abdomen  may  first  attract  attention.  The 
walh  is  careful,  and  a  peculiar  tip-toeing  step,  the  feet  being 
slightly  inverted  to  avoid  the  jar  of  striking  the  heels,  is  often 
observed;  this  is,  hov^ever,  not  a  peculiarity  of  disease  of  this 
region  alone,  but  is  rather  an  evidence  that  the  spine  is  sensitive 
to  slight  jars.  More  characteristic  of  lumbar  disease  is  a  pecu- 
liar swagger  explained  in  part  by  the  exaggerated  lordosis,  and 


40  ORTHOPEDIC    SVBGEBY. 

in  part  by  the  loss  of  the  accommodative,  balancing  motion  of 
the  lumbar  spine,  as  the  weight  falls  alternately  on  each  limb 
in  walking. 

The  increased  lumbar  lordosis,  so  characteristic  of  the  early 
stage  of  the  disease,  is  capable  of  several  explanations.  It  is 
partly  voluntary,  as  bending  the  trunk  forward  brings  pressure 
upon  the  diseased  vertebral  bodies,  so  bending  it  backward  re- 
lieves this  pressure.  It  is  partly  involuntary,  caused  by  the 
contraction  of  the  large  muscular  masses  on  the  posterior  aspect 
of  the  spine ;  and  it  is  in  part  compensatory,  as  the  slight  psoas 
contraction  which  is  often  present  has  a  tendency  to  tilt  the 
pelvis  forward,  necessitating  a  greater  compensatory  backward 
inclination  of  the  body. 

As  the  disease  progresses  the  lumbar  section  becomes 
straighter,  and  finally  it  may  project  backward  in  the  charac- 
teristic angular  deformity.  Yet  even  after  the  lordosis  has 
been  obliterated  the  backward  inclination  of  the  body  still  con- 
tinues as  a  compensation  for  the  change  in  balance,  which  the 
transformation  of  the  forward  curve  to  a  posterior  deformity 
has  necessitated  (Fig.  11).  Thus  overerectness  or  backward 
inclination  of  the  body  characterizes  the  disease  of  this  region 
from  its  beginning  to  its  end  in  uncomplicated  cases. 

Slight  'psoas  contraction  as  a  part  of  the  general  muscular 
spasm  about  the  diseased  area  simply  increases  the  lordosis ;  but 
if  the  contraction  is  greater,  when  for  example  an  abscess  is 
present  which  involves  the  substance  of  the  psoas  muscles  or 
forms  a  painful  tumor  in  the  pelvis,  the  erect  attitude  is  no 
longer  possible.  The  thighs  are  drawn  toward  the  trunk,  and 
the  trunk  is  inclined  forward  to  relax  the  tension.  As  this 
greater  contraction,  with  the  abscess  that  is  usually  its  cause, 
is  commonly  unilateral  the  patient  "favors"  the  flexed  limb, 
and  the  resulting  limp  is  often  mistaken  for  a  sign  of  hip 
disease.  Unilateral  psoas  contraction  is,  in  fact,  so  often 
present  when  the  patient  is  first  brought  for  treatment,  that  a 
limp  and  the  accompanying  inclination  of  the  body  may  be  con- 
sidered as  characteristic  of  disease  of  the  lumbar  region  at  a 
somewhat  advanced  stage  (Fig.  13). 

The  location  of  the  pain  depends  upon  the  distribution  of  the 
nerves  that  supply  the  diseased  vertebrae  or  that  pass  in  their 
vicinity;  it  may  radiate  over  the  inguinal  region  or  backward 
to  the  loins  or  buttocks  or  down  the  front  or  back  of  the  thighs 
to  the  knees.     Painful   "cramp"   is   sometimes   a   prominent 


TUBERCULOUS    DISEASE    OF    TEE    SPINE. 


41 


symptom ;  the  limb  is  siDasmodically  drawn  toward  the  body  and 
the  patient,  seizing  it  with  both  hands,  shrieks  with  pain. 

Lateral  inclination  of  the  body  is  often  present  particularly 
when  the  disease  is  at  the  lumbosacral  articulation.  It  is 
usually  a  symptom  of  unilateral  psoas  contraction  and  abscess ; 


Fig.  12. 


Fig.  13. 


Disease  of  the  lumbar  re- 
gion. First  symptom,  pain  in 
tlie  linees. 


Disease  of  tlie  lumbar  region  with 
right  iliopsoas  abscess  and  psoas  con- 
traction. 


it  may  be  due  also  to  unilateral  contraction  of  the  muscles  of 
the  back,  or  at  a  later  stage  it  may  indicate  collapse  or  destruc- 
tion of  one  side  of  a  vertebral  body.  In  other  instances  it  is 
not  a  fixed  attitude,  but  is  simply  a  voluntary  adaptation  to 


42 


OBTHOPEDIC   SUBGEBY. 


Fig.  14. 


weakness  or  pain ;  thus  one  may  find  a  large  abscess  in  one 
pelvic  fossa  unaccompanied  by  psoas  contraction,  while  the 
body  is  inclined  toward  the  opposite  side,  apparently  because 
the  weight  is  supported  habitually  on  this  limb. 

The  stiffness,  weakness,  and  pain,  characteristic  of  disease  in 
this  region,  are  exemplified  in  many  ways,  for  example,  the  child 
may  be  unabje  to  turn  in  bed ;  it  is  slow  and  awkward  in  rising 

in  the  morning  or  in  changing 
from  an  attitude  of  rest  to  one 
of  activity.  It  often  prefers  to 
stand  rather  than  to  sit,  because 
in  the  latter  position  more 
weight  is  thrown  upon  the  sen- 
sitive vertebral  bodies.  When 
seated,  particularly  when  rid- 
ing in  a  carriage  or  street  car, 
the  patient  often  sits  upright, 
the  hands  resting  instinctively 
on  the  seat  to  steady  and  sup- 
port the  spine. 

Stooping,  a  ]30sture  that  in- 
creases the  pressure  on  the  dis- 
eased vertebral  bodies  and 
which  necessitates  muscular  ten- 
sion and  strain  in  regaining  the 
erect  position,  is  always  avoided 
by  the  patient  if  the  disease  is 
at  all  acute.  For  example,  when 
the  child  is  asked  to  pick  up  an 
object  from  the  floor,  it  either  refuses  or  it  squats  on  the  heels 
or  drops  upon  the  knees  (Fig.  14)  instead  of  flexing  the  spine 
as  in  health.  The  erect  attitude  is  then  regained  by  pushing 
the  body  up  by  the  pressure  of  the  hands  on  the  thighs.  If  the 
child  who  refuses  to  stoop  is  placed  upon  the  floor  it  will,  if 
possible,  seize  the  mother's  skirts  or  it  will  crawl  to  a  chair  or 
other  object  upon  which  the  body  may  be  drawn  up  by  the 
arms,  so  that  the  discomfort  caused  by  contraction  of  the  back 
muscles  may  be  avoided. 

After  the  inspection  of  the  movements  and  attitudes  of  the 
patient,  the  direct  examination  of  the  range  of  passive  motion 
is  made.  The  patient  is  placed  at  full  length,  face  downward, 
on  a  table,  and  the  range  of  extension  and  of  lateral  motion  is 


Lumbar     disease.       The 

picking  up  an  object 


manner     of 


TUBERCULOUS    DISEASE    OF    THE    SPINE. 


43 


tested  by  lifting  the  legs  and  swaying  the  body  gently  from 
side  to  side  (Fig.  15).     The  spine  is  so  flexible  in  childhood 


Fig.  15. 


Showing  the  rigidity  of  the  spine  before  appearance  of  deformity. 
Fig.  16. 


Test  for   psoas   contraction. 


that  rigidity  even  in  the  upper  dorsal  region  may  be  demon- 
strated by  this  method,  and  in  testing  the  lumbar  region  the 
thorax  should  be  fixed  by  the  hand.    One  should  then  examine  for 


44 


OETEOPEDIC    SUBGERY. 


psoas  contraction.  The  pelvis  is  pressed  firmly  against  the  table 
with  one  hand,  while  the  leg,  held  in  the  line  of  the  body,  is 
gently  lifted  by  the  other  (Fig.  16).  The  normal  range  of 
hyperextension  at  the  hip-joint  should  allow  the  knee  to  be 
lifted  two  or  three  inches  from  the  table.  Restriction  of  ex- 
tension of  both  thighs,  indicating  a  slight  degree  of  psoas  con- 
traction, is  very  common  in  lumbar  Pott's  disease ;  but  when  the 
restriction  is  marked,  and  especially  if  it  is  unilateral,  a  deep 
abscess  may  be  suspected.  Such  unilateral  psoas  contraction 
may  be  demonstrated  by  placing  the  child  on  the  back,  allowing 

Fig.  17. 


A  method  of  demonstrating  psoas  contraction. 

the  limbs  to  hang  over  the  edge  of  the  table,  when  the  unaffected 
thigh  will  drop  below  its  fellow  (Fig.  17). 

As  a  rule,  flexion  of  the  spine  is  much  more  restricted  in  the 
early  stage  of  the  disease  than  is  extension ;  this  may  be  demon- 
strated by  placing  the  child  on  its  hands  and  knees,  and  lifting 
it  from  the  floor,  when  the  body,  instead  of  bending  over  the 
supporting  hands,  retains  almost  its  original  contour  (Fig.  18). 

As  has  been  stated,  even  in  early  cases  one  may  detect  often 
a  slight  fulness  about  the  spinous  processes  or  a  slight  irregu- 
larity in  their  line,  about  which  the  muscular  spasm  is  most 
marked;  this  indicates  the  exact  seat  of  the  disease.  Deep 
pressure  on  the  spinous  processes  may  cause  discomfort,  and 
sometimes  greater  elasticity  at  this  point  may  be  demonstrated. 
Except  in  the  hands  of  an  expert,  it  is,  however,  a  test  of  com- 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  45 

parativelj  little  value ;  and  again  it  may  be  mentioned  that 
local  pain  and  local  sensitiveness  to  j)ressure  on  the  spinous 
processes  are  not  characteristic  signs  of  Pott's  disease. 

Finally,  one  should  examine  for  pelvic  abscess.  This  may 
be  suspected  when  unilateral  psoas  contraction  is  present  in 
marked  degree,  although  psoas  contraction  may  be  present 
without  abscess,  and  abscess  may  be  unaccompanied  by  psoas 

Fig.  18. 


Disease  of  the  lumbal-  region  before  the  stage  of  deformity.     A  test  for  rigidity. 

contraction  when  the  substance  of  the  muscle  is  not  involved. 
The  typical  psoas  abscess,  as  pictured  and  described,  is  a 
fluctuating  tumor  that  suddenly  appears  on  the  inner  side  of 
the  thigh,  although  it  may  have  been  many  months  in  descend- 
ing to  this  position  from  its  original  site.  Demonstrable  abscess 
is  present  at  some  time  in  at  least  50  per  cent,  of  the  cases  of 
lumbar  disease,  and  its  detection  is  a  matter  of  importance, 
since  its  subsequent  behavior  will  often  materially  influence 
the  treatment.  The  child  is  placed  on  the  side,  the  thigh  is 
flexed,  and  the  hand  is  pressed  gently  down  into  the  loin  and 


46  OETHOPEDIC    SUEGEBY. 

iliac  fossa.  Sometimes  the  examination  will  be  made  easier  bj 
extending  the  limb  and  thus  bending  the  spine  forward  toward 
the  hand.  Often  in  this  manner  one  can  make  out  a  peculiar 
sausage-like  thickening  on  one  or  the  other  side  of  the  spine,  or 
a  larger,  rounded  tumor  in  the  iliac  fossa,  the  presence  of  which 
would  not  otherwise  have  been  suspected. 

Diagnosis, — If  a  careful  physical  examination  were  made  in 
all  suspicious  cases,  by  one  at  all  familiar  with  the  ordinary 
symptoms  of  Pott's  disease,  the  field  for  differential  diagnosis 
would  be  small  indeed ;  but  it  would  appear  that  such  examina- 
tions are  not  made  usually  by  the  physician  who  is  first  con- 
sulted. One  may  learn,  for  example,  that  the  child  has  been 
circumcised  because  of  pain  about  the  genitals,  or  because  of 
weakness  of  the  limbs,  supposed  to  be  due  to  "  reflex  irritation  "  ; 
or  if  the  patient  is  an  adult,  that  he  has  been  treated  for  sciatica, 
rheumatism,  or  strain,  long  after  the  deformity  even,  would 
have  been  apparent  had  the  back  been  inspected. 

Pott's  disease  is  most  often  mistaken  for  some  one  of  the  fol- 
lowing affections : 

Lumbago. — This  may  simulate  some  of  the  symptoms  of 
Pott's  disease  of  this  region,  but  it  is  of  sudden  onset,  usually 
accompanied  by  local  pain  and  sensitiveness  of  the  muscles 
themselves. 

Stkaix  of  the  Back. — This  is  often  accompanied  by  stiff- 
ness and  pain  on  motion,  but,  like  lumbago,  its  onset  is  sudden 
and  its  cause  is  known.  The  pain  is  usually  localized  at  the 
point  of  injury;  it  is  relieved  by  rest,  and  the  restriction  of 
motion  is  in  great  degree  voluntary.  In  Pott's  disease  the  pain 
is  neuralgic ;  it  is  often  worse  at  night  and  the  rigidity  is  due 
to  reflex  spasm. 

Sciatica. — The  pain  of  sciatica  is  most  often  unilateral ;  it 
is  usually  confined  to  the  distribution  of  this  nerve,  which  is 
often  sensitive  to  pressure  throughout  its  course.  The  pain  of 
Pott's  disease,  if  it  is  referred  to  the  limbs,  is  usually  bilateral 
and  the  nerve  trunks  are  not  often  sensitive  to  pressure.  In 
sciatica,  movements  of  the  limbs  that  cause  tension  on  the  nerve 
are  often  painful,  while  motion  of  the  spine  is  free,  or  but 
slightly  restricted,  the  reverse  of  the  symptoms  of  Pott's  disease. 
It  is  true  that  lateral  deviation  and  even  rigidity  of  the  lumbar 
spine  are  sometimes  observed  in  cases  of  lumbosciatic  neuralgia 
of  long  standing,  but  if  the  latter  symptom  is  marked  the 
diagnosis  may  be  regarded  as  open  to  question. 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  47 

Spondylitis  Deformans. — This  disease  is  practically  con- 
fined to  adult  life  and  is  far  more  often  mistaken  for  lumbago 
than   for   tuberculous    disease.      It    is    described   in    detail    in 

Chapter  II. 

Fig.  19. 


Disease  of  the  lower  dorsal  region.     The  earliest  indication  of  deformity. 

Spondylolisthesis. — This  is  a  very  uncommon  affection  in 
early  life.  It  may  simulate  disease  at  the  lumbosacral  articu- 
lation. A  description  of  its  peculiarities  will  be  found  in  Chap- 
ter II. 

Saceoiliac  Disease. — Sacroiliac  disease  is  far  more  likely 
to  be  mistaken  for  disease  of  the  hip-joint  than  of  the  spine ; 
the  pain  and  sensitiveness  are  usually  localized  about  the  seat 
of  disease  and  the  movements  of  the  spine  are  not  restricted, 
except  in  cases  of  long  standing. 


48  OBTHOPEDIC    SUBGEEY. 

Lumbago,  sciatica,  and  sacro-iliac  disease  are  extremely  un- 
common in  childhood,  and  if  supposed  strains  or  injuries  of  the 
back  cause  persistent  symptoms,  the  appropriate  treatment 
would  be  similar  to  that  of  Pott's  disease ;  that  is  to  say,  the 
susj)ected  part  should  be  supported  until  the  cause  of  the  symp- 
toms is  made  clear. 

The  attitude  characteristic  of  Pott's  disease  of  this  region, 
the  hollow  back,  the  prominent  abdomen,  and  the  swaying  gait, 
may  be  simulated  by  bilateral  congenital  dislocation  of  the  hip, 
in  which  the  pelvis  is  suspended  at  a  point  behind  its  normal 
position ;  but  in  this  instance  the  gait  and  attitude  have  existed 
since  the  child  began  to  walk,  and  the  symptoms  of  the  disease 
are  absent.  A  similar  attitude  is  sometimes  caused  by  weakness 
or  paralysis  of  the  muscles  of  the  back,  as,  for  example,  in  the 
muscular  dystrophies.  In  such  affections  there  may  be  also  a 
disinclination  to  stoop,  and  there  may  be  limitation  of  motion, 
symptoms  that  bear  a  superficial  resemblance  to  Pott's  disease ; ' 
but  as  there  are  no  other  signs  of  disease  of  the  spine,  it  may 
be  readily  excluded. 

When  psoas  contraction  is  present  the  resulting  limp,  often// 
accompanied  by  pain  in  the  limb,  is  almost  invariably  mistakenjj 
for  a  symptom  of  hip  disease.  '■ 

Although  flexion  of  the  thigh  caused  by  psoas  contraction  is  a 
common  accompaniment  of  Pott's  disease,  it  is  not  usually  an 
early  symptom;  thus  the  history  will  probably  call  attention  to 
symptoms  referable  to  the  spine,  that  have  preceded  it.  Again, 
the  limp  of  Pott's  disease  is  caused  simply  by  flexion  of  the 
limb,  and  if  the  tension  of  the  contracted  iliopsoas  muscle  is  re- 
lieved by  flexing  the  thigh  still  further,  the  other  movements  at 
the  hip,  abduction,  adduction,  rotation,  and  flexion,  are  free  and 
painless.  Thus,  hip  disease,  in  which  all  movements  are  re- 
strained in  equal  degree  by  muscular  spasm,  may  be  excluded 
readily,  except,  perhaps,  in  infancy. 

Hip  Disease  in  Infancy. — At  this  susceptible  age  sympa- 
thetic spasm  of  the  lumbar  muscles  may  accompany  acute  affec- 
tions of  the  hip,  and  similar  spasm  of  the  hip  muscles  may  be 
present  in  Pott's  disease  of  the  lower  part  of  the  spine. 

Several  examinations  may  be  necessary  before  the  exact  loca- 
tion of  the  disease  can  be  determined,  and  in  doubtful  cases 
the  application  of  a  temporary  support  to  the  back  and  thigh, 
such  as  a  spica-plaster  bandage  to  relieve  the  sympathetic  spasm, 
is  useful  as  an  aid  in  diagnosis. 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  49 

It  has  been  stated  that  extension  of  the  thigh  only  is  re- 
strained by  psoas  contraction.  It  will  be  evident,  however,  that 
the  presence  of  a  large  and  painful  abscess  in  the  pelvis  or  thigh 
may  limit  motion  in  other  directions  as  well ;  but  even  in  such 
cases  at  least  one  movement  is  unrestrained ;  thus  disease  within 
the  joint  may  be  excluded. 

Secondary  Hip  Disease. — In  Pott's  disease  of  long  stand- 
ing, complicated  by  abscess,  in  which  the  tissues  about  the  joint 
are  infiltrated  or  traversed  by  discharging  sinuses,  secondary 
infection  of  the  hip-joint  is  not  an  unusual  complication.  In 
such  cases,  when  the  limb  is  distorted  and  when  motion  at  the 
hip  is  limited  by  the  sensitive  and  contracted  tissues,  it  is  not 
easy  to  determine  the  presence  or  absence  of  joint  disease. 
Doubtful  cases  of  this  class  should  be  treated  symptomatically. 

Pelvic  Abscess. — As  abscess  is  such  a  common  complica- 
tion of  Pott  s'Hisease,  it  will  be  necessary  to  consider  abscesses  of 
other  origin,  that  may  cause  occasionally  symptoms  resembling 
somewhat  those  of  disease  of  the  spine.  Such  are  the  perine- 
pJiritic  abscess,  and,  more  rarely,  that  of  appendicitis.  They 
differ  from  the  abscess  of  Pott's  disease  in  that  they  are,  as  a 
rule,  acute  in  their  onset  and  are  accomj)anied  by  constitutional 
symptoms  and  by  local  pain  and  sensitiveness.  In  such  cases  the 
motions  of  the  spine  may  be  restrained,  but  the  restraint  is  in 
great  degree  voluntary,  quite  different  from  the  rigidity  due  to 
disease  of  its  substance.  It  is  true  that  the  pelvic  abscess  of 
Pott's  disease  which  has  become  infected  may  cause  constitu- 
tional symptoms,  but  the  history  of  the  disability  and  discom- 
fort that  must  have  preceded  the  abscess,  together  with  the 
probable  presence  of  deformity,  will  make  the  diagnosis  clear. 
Chronic  abscess  in  the  pelvis  of  other  than  spinal  origin  may  be 
the  result  of  disease  of  the  pelvic  bones,  or  of  the  sacroiliac 
articulation,  or  of  the  hip-joint.  It  may  be  caused  by  the 
breaking  down  of  lymphatic  glands,  or  it  may  have  its  origin 
in  inflammation  about  the  uterine  appendages,  and  cases  of  so- 
called  idiopathic  inflammation  and  suppuration  of  the  iliopsoas 
muscle  have  been  described.  In  childhood,  chronic  abscesses  in 
this  locality  are  almost  always  tuberculous  in  character,  and  are 
caused  by  disease  of  bone,  either  of  the  spine  or  of  the  pelvis. 
Disease  of  the  spine  can  be  determined  usually  by  the  methods 
already  indicated,  but  if  the  abscess  is  of  other  origin  its  exact 
cause  can  be  decided  in  many  instances  only  by  an  operative 
exploration.  Abscesses  of  this  character,  of  slow  and  apparently 
4 


50  OETHOPEDIC    SVFiGEIlY. 

painless  formation,  mav  finally  cause  a  swelling  in  the  inguinal 
region  or  about  the  saphenous  opening,  that  in  the  adult  is  not 
infrequently  mistaken  for  hernia.  In  practically  all  cases,  how- 
ever, the  tumor  of  the  abscess  may  be  made  out  on  palpation 
within  the  pelvis,  and,  although  the  contents  of  the  external  sac 
may  be  in  part  forced  back  into  the  larger  reservoir,  its  reduc- 
tion is  very  diiferent  in  feeling  from  that  of  a  true  hernia. 

Peculiarities  of  Lumljar  Pott's  Disease  in  Infancy. — Attention 
has  been  called  repeatedly  to  the  great  importance  of  careful 
observation  of  the  postures  and  movements  of  the  patient,  to 
the  change  in  the  contour  of  the  spine,  and  particularly  to  the 
abnormal  lordosis  and  peculiar  attitude  of  overerectness  in  the 
early  stage  of  disease.  But  the  description  of  attitudes  of 
standing  and  walking,  and  of  the  contour  of  the  spine  which 
is  the  result  of  the  erect  posture,  does  not  apply  to  the  infant 
in  arms,  nor  can  the  spine  be  divided  into  contrasting  sections 
for  the  purpose  of  differential  diagnosis.  In  Pott's  disease  of 
infancy  the  muscular  spasm  is  usually  more  intense  and  its 
extent  is  greater;  the  child  screams  when  it  is  moved  or  when 
the  diapers  are  changed.  Slight  irregularity  of  the  spinous 
processes  indicating  the  position  of  the  destructive  process  is 
often  evident  and  abscess  is  not  unusual.  There  is  usually  no 
difficulty  in  determining  the  presence  of  disease  even  in  very 
early  cases,  but,  as  has  been  mentioned,  it  is  sometimes  difficult 
to  decide  whether  the  lumbar  spine  or  one  of  the  hip-joints  is 
involved. 

Pott's  disease  of  infancy  may  be  mistaken  for  acute  rliacliitis, 
or  scurvy.  The  symptoms  of  such  affections  are,  however,  not 
limited  to  the  spine,  but  involve  to  a  greater  or  less  degree  the 
limbs  and  joints,  indicating  that  the  discomfort  and  pain  are 
due  to  a  general,  not  to  a  local  disease. 

The  Rhachitic  Spine. — The  deformity  of  the  spine,  caused  by 
rhachitis,  is  not  infrequently  mistaken  for  that  of  Pott's  disease. 

It  has  been  stated  that  when  in  early  infancy  the  child  is 
placed  in  the  sitting  posture  the  spine  bends  in  a  long,  posterior 
curve,  indicative  of  the  weakness  normal  at  this  age.  Such  a 
curvature  is  characteristic  also  of  acquired  weakness  and  par- 
ticularly that  caused  by  rhachitis  in  early  childhood.  The  weak 
child  that  has  never  walked  or  that  has  ''lost  its  walk"  sits 
much  of  the  time  in  its  chair,  or  is  carried  about  on  its  mother's 
arms.  In  this  posture  the  spine  is  habitually  bent  backward. 
Soon  a  slight  projection  persists,  even  when  the  child  is  lying 


TUBEBCULOUS    DISEASE    OF    TEE    SPINE.  51 

down.  This  usually  increases  in  size  and  becomes  more  re- 
sistant, forming  a  somewhat  rounded  and  resistant  posterior 
curvature  of  the  dorsolumbar  portion  of  the  spine. 

The  diagnosis  from  Pott's  disease  should  be  made  without 
difficulty,  because  the  evidences  of  general  rhachitis  being 
present,  the  deformity  is  almost  as  much  to  be  expected  as 
would  be  distortions  of  the  legs  were  the  child  walking.  If  the 
patient  is  placed  in  its  habitual  sitting  posture  it  will  be  seen 
that  the  deformity  is  simply  an  exaggeration  of  a  normal  atti- 
tude. In  this  attitude  the  patient  remains  contentedly  for  an 
indefinite  time,  whereas  if  Pott's  disease  were  present  the  child 
would  lie  on  its  back  or  abdomen.  '  The  projection  is  rounded, 
not  angular,  and  if  the  patient  be  placed  in  the  prone  posture 
the  projection  may  be  reduced,  in  great  part,  by  raising  the 
thighs  while  gentle  pressure  is  exerted  upon  the  kyphosis. 
Finally,  although  such  extension  and  pressure  may  cause  dis- 
comfort, there  is  complete  absence' of  the  muscular  spasm  char- 
acteristic of  Pott's  disease. 

It  may  be  stated,  then,  that  the  rhachitic  deformity  is  a 
rounded  curvature  of  the  lower  part  of  the  spine.  Its  cause  is 
weakness  and  habitual  posture.  The  rigidity  depends  upon  the 
duration  of  the  deformity.  The  pain,  if  the  rhachitis  be  acute, 
is  general  and  it  is  easily  explained  by  the  sensitive  condition 
of  the  bones  and  joints.  It  is  true  that  rhachitis  and  tubercu- 
lous disease  of  the  spine  may  be  combined,  but  in  such  rare 
instances  the  symptoms  of  the  more  serious  local  disease  will 
make  themselves  evident  as  distinct  from  those  of  the  general 
weakness. 

Summary.. — The  more  characteristic  symptoms  of  disease  of 
the  dorsolumbar  region  are: 

Increased  lordosis  or  overerectness  and  a  prominent  abdomen  ; 
a  cautious,  constrained,  or  waddling  gait;  less  often  a  lateral 
inclination  of  the  body  or  a  limp  caused  by  psoas  contraction. 

Stiffness  of  the  spine,  which  makes  bending  or  turning  the 
body  difficult. 

Pain  referred  to  the  back,  to  the  inguinal  region,  or  to  the 
thighs,  and  in  more  advanced  cases  the  characteristic  deformity. 
j  Disease  of  the  Thoracic  Region  of  the  Spine. — The  normal 
movement  of  this  section  of  the  spine,  which  includes  the  third 
and  tenth  vertebrae,  is  as  compared  with  those  above  and  below 
it,  slight ;  thus,  disease  of  this  region  may  not  interfere  to  a 
noticeable  degree  with  the  general  functions  of  the  spine. 


52  OBTHOPEDIC    SUBGEBY. 

As  this  part  of  the  column  curves  backward,  the  deformity, 
often  unattended  bj  severe  symptoms,  is  not  infrequently  mis- 
taken for  round  shoulders  (Fig.  20).  It  seems  probable,  also, 
because  of  the  normal  backward  curve,  and  because  of  the  lever- 
age exerted  by  the  weight  of  the  head  and  arms,  that  deformity 

Fig.  20.  Fig.  21. 


Pott's    disease    of    the    middle    doi-sal 
region  at  an  early  stage,  showing  slight        Disease    of    the    upper    dorsal    re- 
increase  of  the  dorsal  kyphosis,  without  gion.      Characteristic   attitude, 
noticeable  change  in  the  attitude.     Con- 
trast with   Fig.   21. 

quickly  follows  disease.  At  all  events,  patients  are  not  often 
seen  before  it  is  present,  so  that  the  diagnosis  is  usually  evident 
on  inspection  of  the  patient. 

The  attitudes  are  not  especially  significant.  Tf  the  lower 
part  of  the  region  is  involved,  and  if  the  disease  is  at  all  acute, 
they  are  similar  to  those  of  disease  of  the  lower  region,  viz.. 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  53 

erectness,  the  peculiar,  cautious,  in-toeiug  step,  and  the  disin- 
clination to  bend  the  body  forward  (Fig.  19). 

If,  on  the  other  hand,  the  upper  part  is  affected,  the  attitude 
is  often,  particularly  in  young  children,  one  of  weakness ;  there 
is  a  slight  forward  inclination  of  the  body,  the  head  being  tilted 
backward  or  inclined  toward  one  side,  and  a  peculiar  shrugging, 
squareness,  and  elevation  of  the  shoulders  is  often  noticeable 
(Fig.  21).  In  many  instances  the  apparent  elevation  of  the 
shoulders  is  in  reality  caused  by  the  deformity,  which  shortens 
the  neck  and  lowers  the  head  (Fig.  23). 

In  this  connection  it  should  be  mentioned  that  one  of  the 
secondary  effects  of  the  disease,  the  so-called  pigeon  chest,  may 
first  attract  the  attention  of  the  parent.  The  forward  inclina- 
tion of  the  spine  causes  a  flattening  of  the  upper  part  of  the 
chest,  while  the  sternum  sinks  downward  and  becomes  promi- 
nent; thus,  the  anteroposterior  diameter  of  the  thorax  is  in- 
creased, and  it  is  compressed  from  side  to  side,  resembling  very 
closely  the  deformity  of  rhachitis.  As  the  pigeon  chest  of  Pott's 
disease  is  always  secondary  to  the  spinal  deformity,  its  cause, 
of  course,  becomes  apparent  on  examining  the  back. 

Of  the  early  symptoms  of  disease  of  the  thoracic  region,  pain 
and  labored  or  "grunting"  respiration  are  the  most  character- 
istic. Pain  referred  to  the  abdomen  and  to  the  front  and  sides 
of  the  chest  is  usually  an  early  and  often  a  constant  symptom ; 
thus,  persistent  "  stomach-ache  "  in  a  child  should  always  lead 
to  an  examination  of  the  spine.  A  "  spasm  of  pain  "  is  some- 
times excited  by  lateral  compression  of  the  chest,  as  when  the 
child  is  lifted  suddenly  by  the  parent. 

Of  much  greater  importance,  however,  is  the  labored  or 
grunting  respiration,  which,  indeed,  is  almost  pathognomonic 
of  Pott's  disease.  This  "  grunting "  is  caused  by  the  inter- 
ference with  respiration,  more  particularly  with  the  normal 
rhythmical  movements  of  the  ribs.  The  restraint  is,  in  part, 
due  to  muscular  spasm  and  to  deformity  and  in  part  to  the 
voluntary  effort  of  the  patient.  The  inspiration  is  quick  and 
shallow,  in  great  degree  diaphragmatic,  and  expiration  is  ac- 
companied by  a  sigh  or  grunt.  This  is  caused  apparently  by  a 
momentary  closure  of  the  larynx  to  resist  the  escape  of  air  and 
thus  sudden  motion  of  the  chest  walls.  Grunting  respiration  is, 
of  course,  an  evidence  of  the  more  acute  type  of  disease,  but  even 
in  mild  cases  will  be  noticed  when  the  i^atient  is  fatigued  or 
during  play. 


54 


OETHOPEDIC    SUEGEBY. 


Fig.  22. 


An  aimless  cough  may  be  symptomatic  of  disease  of  the  upper 
dorsal  region,  and  spasmodic  attacks  resembling  asthma  are 
not  uncommon. 

In  most  instances  the  characteristic  deformity  is  present  on 
examination,  and  in  the  exceptional  cases  in  which  it  is  absent 

a  slight  change  in  contour  will  be 
apparent  when  the  trunk  is  flexed. 
In  place  of  the  long,  regular  curve 
of  the  normal  spine  a  point  where 
two  distinct  outlines  unite  will  be  ob- 
served— one  of  which  may  be  curved, 
while  the  other  is  practically  straight 
(Fig.  7). 

Muscular  spasm  appears  on  sud- 
den movement  of  the  spine,  and  it 
may  be  demonstrated  in  children  by 
raising  the  legs  and  swaying  the  body 
from  side  to  side  (Fig.  15).  The 
change  in  the  rhythm  of  respiration 
has  been  mentioned.  Although  the 
respiratory  movement  of  the  entire 
thorax  is  lessened  in  range,  the  re- 
straint does  not  affect  all  the  ribs' 
equally;  those  that  articulate  with 
the  diseased  vertebrae  are  often  nearly 
motionless,  while  the  movement  of 
those  at  a  distance  from  the  disease 
may  approach  the  normal. 

In  tracing  the  neuralgic  pain  to 
its  source  the  sharp,  downward  in- 
clination of  the  ribs  must  be  borne 
in  mind;  thus,  the  cause  of  pain  in 
the  "  stomach "  must  be  looked  for 
between  the  shoulder  blades. 

As   in   the  lumbar   region,    slight 
lateral  deviation  of  the  spine  is  not 
uncommon,  and  it  may  be  accompanied  by  a  noticeable  twist 
or  rotation  so  that  the  ribs  on  one  side  project  slightly  back- 
ward (Fig.  22). 

In  this  region  the  spinal  cord  is  more  often  involved  than  in 
disease  of  other  sections ;  thus,  an  awkward,  stumbling  gait  and 
finally  "loss  of  walk"  may  first  attract  attention.     The  paraly- 


Marked  lateral  deviation  of 
the  spine  with  rotation.  De- 
formity at  the  eighth  dorsal 
vertebra. 


TUBEBCULOUS    DISEASE    OF    THE    SPINE. 


55 


sis  of  Pott's  disease  and  its  differential  diagnosis  are  considered 
in  more  detail  elsewhere. 

Abscess  as  a  complication  of  disease  of  the  thoracic  region 
cannot  be  demonstrated  by  palpation  unless  it  has  found  an 
outlet  between  the  ribs,  but  percussion  will  often  show  an  area 
of  dulness  or  flatness  extending  from  the  diseased  vertebrae 
toward  the  lateral  aspect  of  the  chest.     This  is  due  in  part. 

Fig.  23. 


Double  psoas   contraction   of  an   extreme  degree   and   paralysis.     The  arms  used 

as  supports. 

however,  to  the  inflammatory  thickening  of  the  tissues  in  the 
neighborhood.  In  rare  instances  the  abscess  may  press  directly 
upon  the  trachea  or  bronchi  and  cause  spasmodic  attacks  of 
dysi^noea  resembling  asthma. 

Diagnosis. — It  is  hardly  necessary  to  mention  the  list  of  affec- 
tions that  may  cause  pain  in  the  chest  or  abdomen;  it  is  suffi- 
cient to  state  that  such  symptoms  always  require  a  physical 
examination.  The  same  statement  applies  to  irregular  respira- 
tion, to  cough,  and  to  so-called  asthma. 


56  OBTHOPEDIC    SUBGEEY. 

Occasionally  tubercnloTis  disease  of  the  thoracic  section  in 
adolescence  is  j)ractically  painless,  and  the  resulting  deformity 
is  rather  rounded  than  angular,  so  that  it  may  be  mistaken  for 
round  shoulders.  ''Round  shoulders"  is,  however,  as  a  rule, 
of  long  duration.  The  exciting  cause  or  causes  of  postural  de- 
formity, in  occupation  or  otherwise,  are  indicated  often  by  the 
history.  The  rigidity  is  less  marked  than  in  Pott's  disease, 
and  neuralgic  pain  is  absent. 

The  contour  of  the  rhachitic  kyphosis  has  been  described.  It 
should  be  evident  that  a  more  or  less  angular  projection  in  the 
upper  part  of  the  spine  could  not  be  rhachitic ;  and  yet  because 
of  the  absence  of  pain  this  diagnosis  is  made  not  infrequently, 
and  as  a  consequence  the  activity  of  the  tuberculous  disease 
may  be  increased  by  massage  and  exercises. 

Lateral  deviation  of  the  spine  as  a  symptom  of  disease  hardly 
could  be  mistaken  for  the  ordinary  rotary-lateral  curvature,  in 
which  pain  and  muscular  rigidity  are  absent. 

Acute  affections  within  the  chest,  pleurisy,  pneumonia,  and 
empyema,  are  sometimes  accompanied  by  lateral  deviation  of 
the  spine,  but  the  sudden  onset  and  the  constitutional  and  local 
symptoms  that  accompany  such  affections  should  make  the 
cause  of  the  deformity  and  pain  evident.  It  is  because  these 
cases  are  sometimes  sent  to  orthopedic  clinics  for  braces  that 
they  seem  worthy  of  mention. 

The  abscesses  in  this  region,  as  has  been  mentioned,  cause 
usually  dulness  or  flatness  on  percussion  of  the  chest,  and  within 
this  area  friction  sounds  and  rales  may  be  heard.  The  tuber- 
culous fluid  may  remain  indefinitely  in  the  posterior  mediasti- 
num and  the  area  of  flatness  may  extend  beyond  the  axillary 
line,  yet  it  may  give  rise  to  no  symptoms.  If  the  diagnosis  of 
Pott's  disease  had  not  been  made  or  if  the  presence  of  the 
abscess  had  not  been  determined  by  the  previous  physical  ex- 
amination, it  might  be  mistaken,  during  an  acute  exacerbation 
of  the  disease  or  constitutional  disturbance  from  other  cause, 
for  pleurisy  or  empyema  or  even  for  phthisis.  In  all  cases, 
therefore,  a  careful  examination  of  the  chest  should  be  made 
from  time  to  time  in  order  that  the  presence  or  absence  of  ab- 
scess may  be  recorded. 

Summary.. — Pott's  disease  of  the  thoracic  region  is  often  in- 
sidious in  its  onset,  causing  no  positive  symptoms  before  the 
stage  of  deformity. 

Its  most  characteristic  symptoms  are  pain  referred  to  the 
front  and  sides  of  the  body  and  the  grunting  respiration. 


TUBEBCULOUS    DISEASE    OF    THE    SPINE. 


57 


If  the  disease  is  progressive,  weakness  and  stiffness  are 
present.  The  attitude,  when  the  disease  is  in  the  lower  thoracic 
region,  resembles  that  of  Inmbar  disease ;  if  the  upper  part  is 
affected  the  head  is  tilted  somewhat  backward  and  the  shoulders 
appear  to  be  elevated. 

2.  Disease  of  the  Upper  Region. — The  upper  region  of  the 
spine,  which  includes  the  cervical  and  two  of  the  dorsal  ver- 

FiG.  24. 


Cervical   disease  with  abscess.     Characteristic  attitude. 


tebrse,  corresponds  in  freedom  of  movement  and  in  its  contour 
to  the  lumbar  region.  From  the  functional  standpoint  it  may 
be  divided  into  two  parts.  Of  these,  the  superior  or  occipito- 
axoid  section  is  peculiar,  in  that  it  contains  no  vertebral  body 
or  intervertebral  cartilage,  and  in  that  the  movements  of  the 
head  are  carried  out  in  special  joints  and  are  controlled  by 
special  muscles.  Occipitoaxoid  disease  is  relatively  more  fre- 
quent in  adult  life  than  in  childhood  and  it  is  as  compared  to 
disease  of  other  regions  of  the  spine  more  dangerous  because  of 


58 


OBTEOPEDIC    SURGERY. 


the  proximity  of  the  vital  centers  which  may  be  injured  by 
pressure  or  by  sudden  displacement  of  the  weakened  vertebrae. 
Symptoms. — In  a  typical  case  the  symptoms  are  neuralgic 
pain  radiating  over  the  back  and  sides  of  the  head,  following 
the  distribution  of  the  auricular  and  occipital  nerves.  The 
neck  is  stiff  and  the  head  may  be  fixed  in  the  median  line,  the 
chin  being  somewhat  depressed;  or  more  often  it  is  tilted  to 
one  side,  simulating  the  attitude  of  torticollis  (Fig.  24). 

Fig.  25. 


Cervical   disease.     A   characteristic   attitude. 


The  attitude  and  appearance  of  the  patient,  when  normal 
movement  of  the  neck  is  restrained  by  a  painful  disease,  is 
characteristic ;  the  eyes  follow  one,  or  the  body  is  turned,  when 
the  attention  of  the  patient  is  attracted.  The  patient  moves 
carefully,  in  order  to  avoid  jar;  often  the  chin  is  instinctively 
supported  by  the  hand,  and  a  favorite  attitude  is 'one  in  which 
the  patient  sits  with  elbows  on  the  table,  the  hands  supporting 
the  head  (Fig.  25).     If  the  attempt  is  made  to  raise  the  chin, 


TUBEPiCULOUS    DISEASE    OF    THE    SPINE.  59 

or  to  rotate  the  head,  the  patient  seizes  the  hands  of  the  ex- 
aminer, and,  it  may  be,  screams  in  apprehension.  There  may 
be  slight  bulging  and  thickening  of  the  tissues  at  the  seat  of 
disease.  The  affected  vertebrae  are  usually  sensitive  to  direct 
pressure,  and  not  infrequently  deep  fluctuation  in  the  suboc- 
cipital triangle  can  be  made  out. 

The  atloaxoid  junction  lies  just  behind  the  posterior  wall 
of  the  pharynx,  on  a  line  with  the  upper  teeth.  Here  abscess 
may  appear  early  in  the  course  of  the  disease,  causing  symptoms 
of  obstruction,  such  as  snoring,  change  in  the  quality  of  the 
voice,  difficulty  in  swallowing,  or  spasmodic  attacks  of  so-called 
croup.  If  abscess  is  present  or  if  the  disease  is  at  all  acute,  the 
reclining  posture  sometimes  aggravates  the  symptoms,  so  that 
"  getting  the  child  to  bed  "  is  often  a  tedious  and  difficult  task. 

In  certain  instances  the  location  of  the  disease  whether  of 
the  occipitoatloid  or  of  the  atloaxoid  articulation,  may  be  de- 
termined, but,  as  both  joints  are  to  a  great  extent  controlled  by 
the  same  muscles,  this  is  often  impossible. 

The  uppermost  joint,  that  between  the  atlas  and  occiput, 
permits  the  nodding  movement  of  the  head,  or  flexion  and  ex- 
tension on  the  spine,  the  range  being  about  50  degrees,  while 
the  atloaxoid  joint  permits  rotation  of  the  atlas  about  the  axis 
to  the  extent  of  about  60  degrees  in  either  direction. 

If  the  disease  be  in  the  upper  joint  the  nodding  movements 
should  be  more  restricted  than  those  of  rotation,  and  vice  versa. 
To  make  the  test  one  must  grasp  the  neck  firmly  in  order  to 
restrain  movement  except  in  the  joint  under  examination.  Be- 
cause of  free  motion  in  the  cervical  region  fixation  of  the  upper 
articulations  is  often  overlooked  when  the  disease  is  of  the  sub- 
acute variety. 

The  Lower  Cervical  Region. — The  symptoms  of  disease  of  the 
lower  cervical  section,  although  similar  in  character,  are  often 
less  marked  than  those  of  the  upper  region.  The  cervical  spine 
becomes  straighter,  and  often  a  slight  backward  projection  or 
thickening  indicates  the  position  of  the  disease.  The  head  is 
usually  turned  to  one  side  by  contraction  of  the  lateral  muscles 
in  an  attitude  of  wryneck  (Fig.  26).  The  pain  is  referred  to 
the  neck,  to  the  sternal  region,  or  down  the  arms,  following  the 
distribution  of  the  brachial  plexus. 

In  the  more  advanced  cases  one's  attention  may  be  attracted 
to  the  cervical  region,  because  the  neck  seems  short  and  because 
the  head  is  tilted  backward.     The  entire  back  shows  a  com- 


60 


OETHOPEDIC    SUEGEEY. 


Fig.  26. 


Disease  of  the  middle  cervical  region 
at  an  early  stage. 


pensatory  flattening,  yet  no  deformity  is  apparent  until  the 
occiput  is  raised  and  drawn  forward,  when  a  shelf -like  projec- 
tion may  be  felt  at  what  appears  to  be  the  extremity  of  the 

spine,  but  which  is  really  an 
angular  deformity  at  the  third 
or  fourth  vertebra. 

This  emphasizes  the  impor- 
tance of  careful  observation  of 
the  contour  of  the  spine,  and 
the  necessity  of  explaining  to 
one's  self  every  change  from  the 
normal  that  may  be  noticed. 

Disease  at  ilie  cervicodnrsal 
junction  resembles  in  its  symp- 
toms that  of  the  upper  dorsal 
region.  The  head  is  usually 
tilted  backward  (Fig.  21)  or  it 
may  be  turned  to  one  side.  Dis- 
ease at  this  point  is  often  sub- 
acute in  character,  and  paral- 
ysis from  implication  of  the 
spinal  cord  sometimes  appears 
before  deformity  is  apparent.  Occasionally  irregularity  of  the 
pupils  is  present  because  of  sympathetic  involvement. 

The  spinous  process  of  the  seventh  cervical  or  first  dorsal 
vertebra  is  often  prominent  (vertebra  prominens)  in  normal 
individuals,  and  it  may  be  mistaken  for  the  deformity  of 
disease,  especially  when  pain  is  referred  to  this  region,  as  in 
hysterical  or  hypersesthetic  cases.  If  such  projection  is  symp- 
tomatic of  disease  there  is  almost  always  a  slight  compensatory 
flattening  of  the  spine  below  the  point  and  a  certain  degree  of 
rigidity  of  the  surrounding  muscles. 

Diagnosis. — As  stiffness  and  distortion  of  the  neck  are  the 
most  prominent  symptoms  of  disease  of  this  region,  one  must 
consider  first  the  forms  of  torticollis  for  which  it  might  bo  mis- 
taken. In  typical  torticollis  the  distortion  of  the  head  is  caused 
almost  invariably  by  contraction  of  the  muscles  supplied  in  part 
by  the  spinal  accessory  nerve,  the  sternomastoid,  and  trajiezius, 
thus,  the  chin  is  slightly  elevated  and  turned  away  from  the 
contracted  muscle. 

Congenital  torticollis,  which  has  existed  from  birth,  is  not 
accompanied  by  pain  and  it  eon  Id  hardly  be  mistaken  for  a 
symptom  of  disease. 


TUBEBCULOUS    DISEASE    OF    THE    SPINE. 


61 


Acute  "rheumatic"  torticollis,  "stiff  neck,"  is  a  common 
affection.  It  is  of  sudden  onset,  "in  a  single  night " ;  the 
affected  muscles  are  sensitive  to  pressure;  the  course  of  the 
affection  is  short  and  it  is  of  comparative  insigTiificance. 

A  more  persistent  form  of  acute  torticollis,  characterized  by 
muscular  spasm  and  by  local  sensitiveness,  sometimes  accom- 
panies enlarged  or  suppurating  cervical  glands;  it  may  follow 

Fig.  27. 


Deformity  at  the  cervical  vertebra  indicated  by  the  vrrinkle  in  the  neck.  The 
attitude  of  the  head  and  the  compensatory  projection  in  the  lumbar  region  are 
characteristic. 


"ear-ache,"  "tonsillitis,"  "sore-throat,"  or  any  form  of  irri- 
tation about  the  pharynx.  This  form  of  wryneck  is  not  only 
very  painful,  but  it  may  persist  indefinitely,  and  permanent 
deformity  may  result.  The  onset  is  usually  sudden;  the  pain 
and  sensitiveness  are  local  and  are  confined,  as  a  rule,  to  the 
contracted  part.  The  sternomastoid  and  trapezius  muscles  are 
most  often  involved;  thus,  the  wryneck  is  typical.  If  the  ten- 
sion be  relaxed  by  inclining  the  head  toward  the  contracted 
muscles,  motion  of  the  spine  itself  will  be  found  to  be  free  and 
painless;  but  if  traction  is  made  on  the  contracted  muscles  it 
causes  discomfort,  and  it  is  usually  resisted  by  the  patient. 


62  OFiTHOPEDIC    SUHGERY. 

lu  disease  of  the  occipitoaxoid  region  the  distortion  of  the 
head  is  by  no  means  typical  of  sternomastoid  contraction;  it 
may  be  tilted  np  or  down  or  laterally  to  an  exaggerated  degree. 
In  other  words,  the  wryneck  of  Pott's  disease  is  an  irregular  dis- 
tortion, because  it  is  not  dependent  on  the  contraction  of  a  par- 
ticular muscle  or  muscular  gToup.  "  In  torticollis  the  chin  is 
turned  away  from  the  contracted  muscle,  while  in  Pott's  disease 
it  is  turned  toward  the  contracted  muscle."  This  is  an  axio- 
matic expression  of  the  fact  that  the  distortion  of  the  head 
symptomatic  of  atloaxoid  disease  depends,  in  g-reat  degree,  upon 
the  sjDasm  of  the  small  muscles  that  directly  control  these  joints, 
the  recti  and  obliqui,  not  upon  the  contraction  of  the  mastoid 
muscle,  as  in  the  ordinary  form  of  wryneck.  Again,  the  con- 
traction, symptomatic  of  Pott's  disease,  of  this  or  other  regions, 
is  the  result  of  muscular  spasm  that  checks  painful  motion. 
If  the  head  be  grasped  firmly  by  the  hands  and  if  gentle  trac- 
tion is  made,  the  distortion  may  often  be  overcome  without  dis- 
comfort to  the  patient.  If  similar  traction  is  made  upon  the 
contracted  muscles  of  acute  wryneck  the  pain  is  increased  and 
the  patient  protests. 

In  disease  of  the  middle  cervical  region,  however,  the  distor- 
tion may  resemble  closely  that  of  acute  torticollis ;  for  if  the 
latter  is  caused  by  the  irritation  of  inflamed  or  suppurating 
glands  there  is  often  sensitiveness  to  manipulation,  with  more 
or  less  general  muscular  spasm.  In  such  cases  the  diagnosis 
may  be  impossible  until  apparatus  has  been  applied  to  rest  the 
part  and  to  correct  the  deformity. 

As  has  been  stated,  the  head  may  be  tilted  backward  to  com- 
pensate for  deformity  in  the  middle  cervical  region,  and  in 
some  instances  it  may  be  drawn  backward  by  spasm  of  the 
posterior  muscles.  Such  a  case  might  be  mistaken  for  cervical 
opisthotonos,  or  posterior  torticollis,  which  is  sometimes  seen  in 
young  infants  suffering  from  exhausting  diseases,  basilar 
meningitis,  and  the  like.  In  such  conditions,  however,  the  char- 
acteristic symptoms  of  Pott's  disease  are,  of  course,  absent. 

The  opposite  attitude,  viz.,  a  forward  droop  of  the  head  due 
to  weakness  of  the  trapezii  muscles,  is  not  uncommon  as  a 
sequence  of  diphthena  or  other  forms  of  contagious  disease. 
This  droop  may  be  accompanied,  also,  by  contraction  of  one  of 
the  sternomastoid  muscles  and  by  pain.  In  such  cases  the 
history  of  the  preceding  affection,  the  weakness  or  paralysis  of 
other  parts,  as  of  the  soft  palate,  of  accommodation  of  the  eyes 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  63 

and  the  like,  together  with  the  general  bodily  weakness  should 
make  the  diagnosis  clear. 

Injury  of  the  upper  segment  of  the  spine,  strain,  contusion, 
or  fracture,  unless  efficiently  treated,  may  cause  symptoms  re- 
sembling very  closely  those  of  tuberculous  disease ;  for  example, 
pain,  radiating  over  the  back  of  the  head,  rigidity  and  deformity 
of  the,  neck,  and  even  infiltration  and  local  tenderness  about 
the  injured  part.  Such  cases,  when  seen  several  weeks  or 
months  after  the  accident,  are  puzzling,  because  one  may  be  in 
doubt  whether  the  symptoms  were  caused  by  a  simple  injury 
or  whether  tuberculous  infection  may  have  followed  or  preceded 
it.  In  such  cases  a  positive  diagnosis  cannot  be  made  until  the 
effect  of  rest  and  protection  has  been  observed — that  is  to  say, 
suspicious  cases  should  be  treated  as  one  would  treat  actual 
disease.  If  the  case  is  simply  one  of  injury  recovery  may  be 
rapid  and  complete,  while  if  disease  is  present  the  symptoms 
only  will  be  relieved. 

The  occipitoaxoid  articulations  may  be  involved  in  acute  or 
chronic  arthritis  and  the  like.  If  the  manifestations  are  general 
in  character  the  diagnosis  is,  of  course,  easily  made;  but  occa- 
sionally the  infection  is  limited  to  the  joints  at  the  upper  ex- 
tremity of  the  spine  and  it  may  be  attended  by  fever  and  consti- 
tutional disturbance.  The  sudden  onset  and  rapid  recovery  if 
proper  treatment  is  applied  are  the  diagnostic  points. 

Abscess  in  the  cervical  region  is  a  secondary  symptom,  and 
although  the  change  in  the  voice  and  the  difficulty  in  breathing 
or  swallowing  may  be  the  most  noticeable  symptoms,  yet  they 
are  always  accompanied  by  some  of  the  characteristic  signs  of 
Pott's .  disease.  Whenever  the  diagnosis  of  cervical  disease  is 
made  one  should  examine  the  throat,  and  whenever  a  chronic 
retropharyngeal  abscess  is  present  one  should  look  for  the  symp- 
toms of  Pott's  disease.  The  diagnosis  of  the  retropharyngeal 
abscess  can  be  made  only  by  inspection  and  palpation ;  therefore, 
one  need  only  mention  the  fact  that  symptoms  of  obstruction 
in  the  throat,  similar  to  those  of  abscess,  may  be  caused  by  ade- 
noid growths  and  by  enlarged  tonsils. 

Retropharyngeal  abscess  by  no  means  always  indicates  Pott's 
disease.  It  may  be  one  of  the  sequelse  of  contagious  disease 
or  a  complication  of  pharyngitis.  It  is  then  rapid  in  its  onset 
and  is  not  accompanied  by  the  symptoms  of  Pott's  disease. 

Summary.. — If  the  disease  is  of  the  upper  or  occipitoaxoid 
region  the  head  is  usually  fixed  in  an  attitude  of  deformity. 


64  OBTHOPEDIC    SUEGEBY. 

which  may  he  slight  or  extreme.  If  the  disease  is  of  the  middle 
region,  the  attitude  more  often  resembles  that  of  ordinary  torti- 
collis. In  the  lower  region  marked  spasm  of  muscles  is  unusual, 
but  the  head  inclines  backward  or  toward  one  shoulder. 

The  contour  of  the  cervical  spine  changes  as  the  disease  pro- 
gresses ;  the  normal  anterior  curvature  is  obliterated ;  thus,  the 
head  is  pushed  forward,  while  the  dorsal  section  of  the  spine 
becomes  flat  or  even  incurvated  in  compensation.  The  seat  of 
the  disease  is  often  shown  by  an  area  of  thickening  or  local 
sensitiveness  to  deep  pressure. 

Diagnosis  in  General. — Weakness  and  the  so-called  "loss  of 
walk  "  are  well-known  symptoms  of  Pott's  disease,  and  on  this 
account  children  suffering  from  various  types  of  weakness  or 
paralysis  are  often  brought  to  orthopedic  clinics  for  the  treat- 
ment of  "  spine  disease." 

Certain  forms  of  paralysis  bear  a  superficial  resemblance  to 
some  of  the  symptoms  of  Pott's  disease;  for  example,  pseudo- 
hypertrophic muscular  dystrophy  to  the  attitude  caused  by 
disease  of  the  lumbar  region,  and  diphtheritic  paralysis  to  that 
of  the  dorsal  region.  Spastic  paralysis,  of  cerebral  origin,  re- 
sembles somewhat  the  paralysis  of  Pott's  disease,  but  it  may  be 
differentiated  by  the  absence  of  pain  by  the  history,  and  by 
what  is  apparent  in  most  cases,  the  mental  impairment. 

Primary  spastic  spinal  paraplegia  resembles  the  paralysis  of 
Pott's  disease  more  closely,  but  the  essential  symptoms  of  a 
destructive  disease  of  the  spine  are  absent.  The  contractions 
combined  with  the  weakness  and  pain  that  sometimes  follow 
cerehrospinal  meningitis  may  be  mistaken  for  the  symptoms  of 
bone  disease,  but  they  are  readily  explained  by  the  history  of 
the  case. 

Forms  of  organic  disease  of  the  spine  other  than  tuberculosis 
as,  for  example,  malignant  disease,  syphilis,  spondylitis  defor- 
mans and  the  like  in  which  the  question  in  dift'erential  diagnosis 
is  not  of  the  presence  or  absence  of  disease  but  rather  of  its 
nature  are  described  in  Chapter  II. 

The  list  of  affections  that  has  been  considered  in  the  differ- 
ential diagnosis  is  a  long  one,  but  it  has  been  made  up  from 
actual  experience.  Mistakes  in  diagnosis  must  be  accounted 
for  usually  by  carelessness  or  ignorance,  or  because  of  insuffi- 
cient opportunity  for  examination ;  but  in  the  earliest  stages  of 
the  disease  repeated  examinations  and  even  tentative  treatment 
may  be  necessary  before  the  diagnosis  is  assured. 


TUBERCULOUS    DISEASE    OF    THE    SPINE. 


65 


The  Roentgen  Ray  Photography  as  a  Means  of  Diagnosis. — Roent- 
gen pictnres  are  of  comparatively  little  importance  from  the 
diagnostic  standpoint,  but  they  may  be  of  value  as  a  means  of 
determining  the  exact  extent  of  the  disease.  If  the  negative  is 
well-defined,  the  diseased  vertebrae  are  seen  to  be  irregular  in 
outline,  or  they  may  be  lost  in  a  peculiar  blur.  By  counting 
from  above  and  below  the  boundaries  of  the  disease  may  be 
made  out,  but  inferences  as  to  its  character  and  quality  must  be 
made  from  the  rational  and  physical  signs  (Fig.  35).  The 
tuberculin  test  is  considered  in  Chapter  V. 

The  Record  of  the  Case. — The  history  and  the  results  of  the 
examination  of  the  patient  should  be  recorded  somewhat  in  the 
following  order: 

1.  The  family  and  the  personal  history. 

2.  The  history  of  the  disease,  with  especial  reference  to  its 
mode  of  onset,  its  probable  duration,  to  the  noticeable  symp- 
toms, and  to  previous  treatment. 

3.  The  physical  examination.  This  should  include  the  gen- 
eral condition  of  the  patient,  the  height  and  weight,  the  attitude, 
the  character  of  the  disease,  whether  progressive,  as  indicated 
by  muscular  spasm  and  pain  on  motion,  or  quiescent,  the  pres- 
ence of  abscess  or  paralysis  as  a  complication,  and,  finally,  the 
position  and  extent  of  the  disease.     This  is  best  shown  by  a 

Fig.  28. 


Tracings    of   the    spine    illustrating   recession    of    deformity    under   treatment    by 
ttie   convex   frame. 

tracing,  made  by  means  of  a  strip  of  lead  or  pure  tin,  of  such 
thickness  that  it  may  be  readily  moulded  on  the  spine  and  yet 
hold  its  shape  when  removed  (Fig.  28). 

The  tracing  should  be  of  the  entire  spine,  made  while  the 
patient  lies  extended  in  the  prone  position,  and  the  exact  loca- 
tion of  the  most  prominent  spinous  process  should  be  marked 
upon  it.  In  determining  the  position  of  the  disease  it  is  well  to 
count  the  spinous  processes  from  below  upward,  beginning  with 
5 


66  OETHOPEBIC   SUBGEEY. 

that  of  the  fourth  lumbar  vertebra,  which  lies  on  a  line  drawn 
between  the  highest  points  of  the  iliac  crests.  There  are  other 
landmarks  that  are  approximately  correct.  Sometimes  the  last 
rib  may  be  traced  to  its  origin ;  the  scapula  covers  the  second 
and  seventh  ribs,  the  root  of  the  spine  of  the  scapula  and  the 
middle  point  of  the  glenoid  cavity  being  on  a  line  with  the  third, 
and  its  inferior  angle  opposite  the  tip  of  the  seventh  dorsal 
spinous  process.  The  upper  margin  of  the  sternum  is  opposite 
the  interval  between  the  second  and  third  dorsal  vertebrae.  In 
many  instances  the  vertebra  prominens  and  the  spinous  process 
of  the  axis  can  be  identified.  Such  landmarks  are,  of  course, 
somewhat  displaced  if  the  deformity  is  extreme,  but  they  are 
always  sufficiently  correct  to  check  errors  in  counting  the 
spinous  processes. 

The  history  furnishes  a  foundation  on  which  treatment  is 
conducted  and  from  which  its  results  may  be  determined.  It 
should  present  therefore  the  condition  of  the  patient  when  treat- 
ment is  begun,  and  in  it  the  complications  and  incidents  and 
the  changes  in  the  treatment  should  be  noted  at  regular  intervals 
while  the  patient  is  under  observation. 

Treatment. — The  general  treatment  of  tuberculous  disease  is 
considered  in  Chapter  V.  Pott's  disease  is  the  most  serious 
of  the  tuberculous  affections  of  the  bones,  and  the  importance 
of  hygienic  surroundings,  nourishing  food,  sunlight,  and,  above 
all,  open  air  both  day  and  night,  if  possible,  can  hardly  be  ex- 
aggerated. 

The  General  Principles  of  Mechanical  Treatment. — Under  normal 
conditions  the  weight  of  the  head  and  of  the  thoracic  and  ab- 
dominal organs  tends  to  bend  the  spine  forward  and  downward 
— a  tendency  that  is  resisted  by  the  action  of  the  muscles  of 
the  back.  If  the  resistance  is  weakened,  as  in  Pott's  disease  by 
the  direct  destruction  of  the  weight-bearing  portion  of  the  spine, 
this  tendency  toward  deformity  is,  of  course,  greatly  increased. 
Thus,  the  pressure  of  the  superincumbent  weight  upon  the 
weakened  part  and  the  strain  of  motion  are,  from  the  mechanical 
standpoint,  the  most  important  factors  in  the  production  of 
deformity. 

When  the  body  is  bent  forward,  the  intervertebral  disks  are 
compressed  and  the  pressure  upon  the  vertebral  bodies  is  in- 
creased. When  it  is  held  erect  or  is  bent  backward  this  pressure 
is  lessened,  and  a  part  of  the  weight  is  transferred  to  the  articu- 
lar processes  and  to  the  posterior  parts  of  the  column.  The 
object  of  a  brace  or  other  support  is  to  hold  the  spine  in  the 


TUBEECULOUS    DISEASE    OF    THE    SPINE.  67 

extended  position,  so  that  pressure  on  the  diseased  vertebrae 
may  be  removed.  One  aims  to  splint  the  spine  as  effectively  as 
if  it  were  broken,  in  order  to  relieve  the  discomfort  and  pain, 
so  depressing  to  the  patient,  and  to  secure  the  rest  that  is 
essential  to  repair. 

The  effectiveness  of  a  particular  splint  or  support,  whether 
applied  to  a  broken  bone  or  to  a  diseased  spine,  depends  upon 
the  area'  that  it  covers  on  either  side  of  the  part  to  be  supported 
and  upon  the  accuracy  of  its  adjustment,  as  well  as  upon  the 
damage  that  the  part  has  already  sustained,  and  the  strain  to 
which  it  still  may  be  subjected. 

From  this  standpoint  it  is  evident  that  it  is  difficult  to  apply 
effective  support  to  the  trunk  because  of  its  size,  shape,  and  con- 
tents, and  it  is  apparent  also  that  the  mechanical  conditions 
are  more  favorable  in  some  parts  than  in  others.  For  example, 
the  splint  should  be  effective  when  the  disease  is  of  the  lower 
dorsal  region,  because  its  two  extremities,  attached  to  the  pelvis 
and  to  the  shouldres,  are  equidistant  from  the  point  to  be  sup- 
ported. The  conditions  are  unfavorable  in  disease  of  the  upper 
thoracic  region,  because  the  weight  of  the  head  and  of  the  arms 
tends  to  increase  the  deformity,  and  because  of  the  insufficient 
-leverage  that  can  be  secured  for  the  supporting  appliance.  The 
pelvis  is  the  base  of  support  for  all  forms  of  splints,  and  if  it  is 
smaller  than  the  abdomen,  as  in  infancy,  ambulatory  appliances 
are  far  less  effective  than  in  older  subjects. 

In  actual  practice  the  treatment  of  Pott's  disease  is  influenced 
by  the  age  of  the  pa,tient,  the  situation  of  the  disease,  the  dura- 
tion of  the  deformity,  and  by  many  other  circumstances,  but 
the  relative  efficiency  of  braces  or  other  appliances  may  be  de- 
cided on  purely  mechanical  grounds.  Thus,  as  the  ultimate 
deformity  of  Pott's  disease  is,  in  great  degree,  caused  by  the 
force  of  gravity  acting  on  a  iveakened  spine,  the  most  effective 
treatment  must  be  fixation  in  the  horizontal  position,  for  in  this 
position  the  strain  of  use  and  the  pressure  of  superincumbent 
weight  can  be  removed  completely. 

Horizontal  Fixation.. — Apparatus  for  this  treatment  must  be 
quite  independent  of  the  bed  on  which  it  may  be  placed,  and  of 
such  appliances  several  forms  are  in  use. 

The  reclinationgypsbettes  of  Lorenz^  is  simply  a  posterior 
case  of  plaster-of-Paris  enclosing  the  head  and  body. 

The  Phelps  bed  is  somev^hat  similar.  A  thin  board  is  cut  in 
the  outline  of  the  child's  body  and  extended  legs.  It  is  padded 
^  Hoffa,  Lehrbuch  der  Orthopadischen  Chir.,  3d    ed.,  p.  324. 


68 


OBTHOPEDIC    SUEGEBY. 


with  wadding  and  covered  with  cotton  cloth ;  the  patient  is  then 
placed  upon  it,  and  plaster  bandages  are  applied  to  enclose  the 
body  and  the  legs.  The  front  is  then  cut  away,  so  that  the 
patient  may  be  removed  from  the  bed  for  an  occasional  bath  and 
change  of  clothing.^ 

The  wire  cuirasse  has  been  popularized  by  Say  re  f  it  is  some- 
what more  cumbersome  and  expensive  than  the  last  appliance 
for  which  it  served  as  a  model.  , 

The  most  effective  and  convenient  form  of  this  type  of  simple 
horizontal  support  is  the  Bradford  frame.     This  is  a  rectangular 

Fig.  29. 


Bradford's   bed-frame.      (Bradford   and   Lovett.) 

frame  of  gas  pipe  a  few  inches  longer  and  slightly  wider  than 
the  patient's  body.  Over,  the  frame  covers  of  strong  canvas  are 
drawn  tightly  by  means  of  corset  lacings  or  straps  on  its  under 
surface,  leaving  an  interval  beneath  the  buttocks  for  the  use  of 
the  bed-pan  (Fig.  29). 

THE   CONVEX   STRETCHER   FRAME. 

The  stretcher  frame'"^  is  made  of  ordinary  galvanized  gas-pipe 
or  steel  tubing  of  a  smaller  diameter.  It  should  be  about  four 
inches  longer  than  the  child  and  about  four-fifths  as  wide,  the 
lateral  bars  corresponding  to  the  articulating  surfaces  of  the 
four  extremities  with  the  trunk.  The  ordinary  dimensions  are 
seven  and  one-half  by  thirty-eight  inches,  or  the  width  to  length 
about  as  one  to  five. 

At  first  thought  it  would  seem  that  the  side  bars  might  cause 
uncomfortable  pressure  on  the  overhanging  shoulders,  but  as 
the  arms  are  set  upon  the  middle  of  the  lateral  aspect  of  the 
trunk  and  thus  on  a  considerably  higher  plane  than  the  dorsum, 

1  The  Phelps  Plaster-of -Paris  Bed,  Trans.  Amer.  Ortho.  Assoc,  1891, 
vol.  iv.,  p.  83. 

-  Kedard,  La  gouttiere  de  Bonnet,  Chir.  Orthopedique,  p.  243. 
^Whitman,  Trans.  Amer.  Ortho.  Assoc,  1901. 


TUBERCULOUS    DISEASE    OF    THE    SPINE. 


69 


there  is  but  bare  contact  when  the  cover  is  fairly  rigid.  Before 
applying  the  cover  one  may  with  advantage  wind  bandages 
tightly  about  the  frame  at  the  point  which  is  to  support  the 
trunk  in  order  to  make  the  support  as  unyielding  as  possible 
(Fig.  30).     The  cover  should  be  of  strong  canvas  suitably  pro- 

FiG.  30.  ; 


iliiiilijJjij 


The  modified  frame  with  the  bandage. 


tected  in  the  center  by  rubber  cloth.  This  is  applied  and  is 
drawn  tight  by  means  of  corset  lacings  and  straps.  Upon  this 
two  thick  pads  of  felt  are  sewed ;  these  should  be  about  seven 
inches  in  length  and  about  an  inch  in  thickness,  placed  on  either 
side  of  the  spinous  processes  at  the  seat  of  the  disease,  thus, 
protecting  them  from  pressure,   fixing  the  part  more  firmly. 

Fig.  31. 


The  stretcher  frame,  showing  the  canvas  cover  and  apron. 

and  increasing  the  leverage  of  the  apparatus.  The  child, 
wearing  only  an  undershirt,  stockings,  and  diaper,  is  placed 
upon  the  frame  and  is  fixed  there  usually  by  a  front  piece  or 
apron  similar  to  that  used  with  the  spinal  brace.  As  soon  as 
the  patient  has  become  accustomed  to  the  restraint  one  begins 
to  overextend  the  spine  by  bending  the  bars  from  time  to  time 
with  the  aim,  as  has  been  stated,  of  actually  separating  the 
diseased  vertebral  bodies  and  obliterating  all  the  physiological 
curves  of  the  spine,  so  that  the  body  shall  be  finally  bent  back- 
ward to  form  the  segment  of  a  circle.  The  greatest  convexity 
is  at  the  seat  of  the  disease,  and  as  the  head  and  lower  extremi- 
ties are  on  a  much  lower  level,  an  element  of  gravity  traction 


70 


OBTHOPEDIC    SURGE  BY. 


is  present  in  some  instances,  while  the  support  of  the  spine,  as 
a  whole,  is  much  more  comprehensive  than  when  the  body  lies 
upon  a  plane  surface   (Fig.   32). 


The  gradual  overextension 


Fig.  32. 


The  frame  bent  to   assure   overextension   of  the  spine.      The   rapid   recession   of 
deformity  in  this  case  is  shown  by  the  tracings,  Fig.   28. 

of  the  spine  by  bending  the  frame  in  this  manner  is  so  definite 
and  simple  that  it  may  be  easily  carried  out  by  the  physician, 
and  it  may  be  exaggerated  slightly,  to  compensate  for  the 
sagging  of  the  cover.  Thus,  it  is  far  more  effective  than  any 
form  of  padding  placed  on  a  flat  surface,  or  other  form  of  sup- 
port with  which  I  am  familiar.  Upon  this  frame  the  child  lies 
constantly,  its  clothing  being  made  sufficiently  large  to  include 
the  apparatus,  thus  assuring  additional  fixation.  Once  a  day  or 
less  often,  the  child  is  removed  from  the  frame  and  is  carefully 
turned,  face  downward,  upon  a  large  pillow;  the  back  is  then 

Fig.  33. 


The  modified  stretcher  frame  showing  overextension  of  the  spine,  with  trac- 
tion for  the  head  and  limbs  as  applied  for  Pott's  paraplegia.  Caused  by  disease 
in   the   upper  dorsal    region.      (See   Fig.    56.) 

inspected,  bathed  with  alcohol  and  powdered,  and  the  apparatus 
is  then  reapplied.  It  is,  of  course,  desirable  to  have  two 
equipped  frames,  but  this  is  by  no  means  essential. 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  71 

The  effect  of  the  continued  fixation  upon  the  back  is  not 
merely  to  change  the  contour  of  the  spine,  but  of  the  entire  trunk 
as  well ;  to  flatten  and  broaden  the  body.  This  increase  of  the 
lateral  at  the  expense  of  the  anteroposterior  diameter  is  quite 
the  reverse  of  the  natural  tendency  of  the  deformity,  and  it  is, 
therefore,  a  favorable  rather  than  an  unfavorable  effect  of  the 
treatment.  The  same  tendency  in  the  lower  region  may  be 
checked  by  the  use  of  a  flannel  binder,  such  as  is  ordinarily 
worn  by  infants. 

Fig.  34. 


A  perfect   cure   obtained  by  the  stretcher  treatment.     The  situation   of  the   dis- 
ease is  shown  in  the  ir-ray  picture,  Fig.   35. 

The  method  of  attaching  the  patient  to  the  frame  varies  some- 
what according  to  the  situation  and  character  of  the  disease. 
In  ordinary  cases,  as  has  been  stated,  a  canvas  apron,  similar  to 
that  used  with  the  back  brace  (Fig.  63),  is  applied,  and  is 
buckled  to  the  sides  of  the  frame.  If  advisable  the  shoulders 
may  be  held  down  by  bands  crossing  the  chest  or  by  axillary 
straps  connected  by  a  chest  band.  If  still  more  effective  fixation 
is  desired,  as  in  disease  of  the  upper  dorsal  region,  the  anterior 


72 


ORTHOPEDIC    SUBGEBY. 


shoulder  brace,  as  used  with  the  back  brace  (Fig.  62),  may  be 
attached  to  the  axillary  straps.     In  disease  of  the  upper  and 


Fig.  35. 


An  x-my  picture  of  the  case  (Fig.  34)  before  treatment.  Tlie  situation  of  the 
disease  at  tlie  junction  of  the  first  and  second  lumbar  vertebra;  is  indicated  by 
the  lateral  deviation,  and  by  the  appi-oximation  of  the  dotted  lines  1  and  2  as 
compared  to  the  others. 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  73 

middle  regions  of  the  spine  restraint  of  the  legs  is  not  necessary, 
but  in  Inmbar  disease  a  broad  swathe  should  be  passed  across 
the  thighs,  and  if  psoas  spasm  is  present  traction  may  be 
employed. 

If  the  disease  is  of  the  upper  region  and  if  the  patient's 
head  is  of  the  long  type,  it  is  advisable  to  make  a  right  angular 
downward  bend  of  the  side  bars  so  that  the  occiput  being  on  a 
lower  level  the  proper  pressure  on  the  spine  may  be  assured. 

Fig.  36. 


The  baby  carriage  as  used  in  hospital  practice  for  patients  on  the 
stretcher  frame. 

In  disease  of  the  upper  region  of  the  spine  traction  is  desir- 
able to  aid  in  the  reduction  of  deformity  and  to  prevent  the 
patient  from  raising  the  head.  This  traction  is  usually  applied 
by  means  of  the  halter  as  used  with  the  jury-mast.  The  straps 
are  attached  to  a  crossbar  at  the  upper  extremity  of  the  frame, 
and  traction  may  be  made  by  simply  tightening  them ;  or  if  the 
upper  part  of  the  frame  is  somewhat  elevated,  the  weight  of  the 
patient's  body  makes  the  proper  countertraction.  This  position 
has  the  advantage,  also,  of  allowing  the  patient  a  better  oppor- 
tunity to  see  what  is  going  on  about  him  (Fig.  33). 

In  disease  of  the  cervical  region  traction  is  usually  of  service 
and  fixation  of  the  head  is  always  indicated  in  addition  when 
the  occipitoaxoid  region  is  involved,  either  by  sand-bags  on 
either  side,  or,  preferably,  by  some  form  of  metal  brace. 


74 


OBTHOPEDIC   SUBGEBY. 


Greater  fixation  of  the  spine  may  be  desirable  in  cases  of  more 
acute  disease.  This  may  be  attained  bj  the  use  of  a  light  back 
brace,  or  a  plaster  jacket,  in  connection  with  the  frame.  Such 
support  should  not  be  applied,  however,  until  the  recession  of 
deformity,  which  is  to  be  expected  under  treatment  by  the  hori- 
zontal fixation  and  overextension,  has  been  obtained  (Fig.  28). 

Fig.  37. 


Pott's  disease  of  the  middle  dorsal  region,  a  type  of  disease  in  wtiich  horizontal 
fixation  is  always  indicated.     H.  S.,  aged  fourteen  months. 


As  this  frame  is  simply  a  horizontal  brace  the  child  may 
spend  as  much  time  in  the  open  air  as  would  be  practicable  were 
any  other  appliance  used. 

I  have  never  seen  other  than  favorable  results  from  this 
method  of  treatment.  Pain  and  discomfort  are,  as  a  rule,  re- 
lieved almost  immediately,  and  there  is  a  corresponding  im- 
provement in  the  general  condition  of  the  patient.  Meanwhile 
the  growth  of  the  trunk,  which  is  so  often  checked  by  the  disease 
and  by  the  deformity,  appears  to  progress  normally,  so  that  the 
apparatus  may  be  actually  outgrown  before  the  termin^^-tion  of 
this  part  of  the  treatment.  Horizontal  fixation  is,  of  course,  a 
treatment  not  complete  in  itself,  since  it  must  be  supplemented 


TUBERCULOUS    DISEASE    OF    THE    SPINE. 


75 


bj  the  usual  supports  when  the  erect  attitude  is  again  assumed. 
Its  duration  varies  from  six  to  eighteen  months.  The  indica- 
tions for  its  discontinuance  are  the  correction  of  deformity,  the 
apparent  quiescence  or  cure  of  the  local  disease  as  indicated  by 
the  physical  signs,  and  by  the  behavior  of  the  patient,  who,  as 
repair  advances,  becomes  restless  when  removed  from  the  frame, 
evidently  desiring  to  sit  and  to  stand. 

It  is  well  to  apply  the  ambulatory  support  some  time  before 
the  patient  is  released  from  the  frame,  permitting  little  by  little 
the  changes  in  attitude  and  habits.  If  the  plaster  jacket  is  to 
be  used  it  may  be  applied  during  longitudinal  suspension  or 

Fig.  38. 


H.    S.,    after   fixation   for   fourteen    months    on   the   stretcher    frame, 
recession  of  deformity.     Compare  with  Fig.   37. 


shows   the 


otherwise,  after  which  the  child  is  immediately  replaced  upon 
the  frame,  where  the  plaster  is  allowed  to  harden ;  thus  it  holds 
the  spine  in  an  attitude  to  which  it  has  become  accustomed 
(Fig.  56). 

Ambulatory  Supports.. — The  two  types  of  ambulatory  supports 
are  the  plaster  jacket  and  the  steel  brace.  The  first  of  these  has 
the  great  advantage  in  that  the  services  of  a  skilled  mechanic  are 
not  essential  and  in  that  the  patient  is  more  under  the  control  of 
the  physician  than  when  removable  apparatus  is  used. 

The  Plaster  Jacket.^ — It  was  claimed  at  one  time  that  a  plaster 
jacket  applied  while  the  body  was  partially  suspended  would 
actually  relieve  the  weakened  area  of  superincumbent  weight  by 


76 


ORTHOPEDIC    SUEGEEY. 


holding  the  diseased  surfaces  apart.  This  is  not  the  fact.  The 
jacket  supports  the  spine  by  holding  it  in  the  erect  or  extended 
position    and   thus   transferring  the   weight   in   part   from   the 


Fig.  39. 


Fig.  40. 


The  plaster  jacket,  illustrating  the 
arrangement  of  the  shirt. 


The  plaster  jacket  supporting  the  ab- 
rlomen.  The  cleansing  bandages  are  not- 
shown. 


diseased  vertebral  bodies  to  the  lateral  and  posterior  portion  of 
the  column. 

Its  efficiency  depends  upon  the  accuracy  of  its  adjustment  to 
the  irregularities  of  the  body,   and  upon  the  leverage  that  it 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  77 

exerts  above  and  below  the  weakened  part.  It  should  be  applied 
while  the  bodv  is  held  in  the  best  possible  position ;  its  inner 
surface  should  be  smooth,  and  the  bony  prominences  that  are 
exposed  to  friction  and  pressure  should  be  protected. 

A  seamless  shirt  fitting  the  body  closely  and  long  enough  to 
reach  to  the  knees  should  be  worn.  These  are  made  in  several  sizes 
and  are  sold  by  the  yard  at  a  low  price.  A  band  of  linen,  China  silk 
or  other  material,  about  three  inches  in  width  and  three  feet  in 
length,  should  be  placed  beneath  the  shirt  on  the  front  and  back. 
These  bands,  or,  as  Lorenz  calls  them,  "  scratchers,"  are  for  the 
l^urpose  of  keeping  the  skin  clean.  The  patient  is  then  placed  upon 
a  stool,  and  the  halter  of  the  suspension  apparatus  is  carefully 
adjusted;  the  arms  are  extended  over  the  head  and  the  hands 
clasp  the  straps  or  rings;  thus,  the  chest  is  expanded  to  its  full 
limit.  Sufficient  tension  is  made  upon  the  rope  to  partially 
suspend  the  body  and  to  draw  the  spine  into  the  best  possible 
attitude ;  in  most  instances  the  heels  should  be  slightly  lifted 
from  the  stool. 

Dr.  Sayre,  to  whom  we  are  indebted  for  the  exposition  of  this 
valuable  means  of  treatment,  insisted  that  the  sensations  of  the 
patient  should  be  the  guide  and  that  traction  should  be  made 
only  to  the  point  of  comfort.  This  is  a  valuable  indication  in 
the  treatment  of  the  adult,  but  it  is  not  often  of  service  in  child- 
hood. 

Before  applying  the  plaster  bandages  pieces  of  piano  felting  or 
similar  material  of  sufiicient  thickness  are  placed  about  the 
anterior  pelvic  spines,  over  the  upper  part  of  the  sternum,  and 
a  thin  strip  is  sometimes  used  to  cover  the  spinous  processes. 
Finally  long  pads  of  saddler's  felt,  or  of  other  material  of  suffi- 
cient thickness,  are  applied  on  either  side  of  the  prominent 
spinous  processes  to  protect  them  from  friction  and  to  provide 
greater  pressure  and  fixation  at  the  seat  of  disease.  In  the 
treatment  of  adolescent  or  adult  females  the  breasts  should  be 
covered  with  a  layer  of  cotton,  which  may  be  removed  later  if 
necessary,  to  prevent  pressure.  The  '"  dinner  pad  "  is  now  not 
often  used,  except  in  the  treatment  of  adults  and  in  certain  eases 
in  which  the  abdomen  is  retracted.  In  childhood  the  abdomen  is 
usually  prominent,  and  extra  space  is  not  usually  required. 
Occasionally,  however,  one  is  told  that  the  patient  complains 
of  discomfort  after  meals,  evidently  due  to  constriction,  and  in 
such  cases  proper  allowance  must  be  made.  The  pad,  which 
is  supposed  to  represent  the  space  necessary  after  a  full  meal, 


78  ORTHOPEDIC    SUBGEBY. 

is  made  by  folding  a  small  towel  into  the  shape  of  a  sandwich ; 
this  is  attached  to  a  bandage  and  is  placed  beneath  the  shirt 
just  below  the  ensiform  cartilage;  when  the  jacket  is  completed 
it  may  be  drawn  out  by  means  of  the  hanging  bandage,  leaving 
the  additional  space  for  emergencies. 

The  materials  for  the  jacket  should  be  of  the  best.  Fresh 
dental  plaster  should  be  rubbed  by  hand  into  strips  of  crinoline, 
free  from  glue.  The  bandages  should  be  from  three  to  five 
inches  in  width  and  six  yards  in  length,  from  three  to  six  being 
required  for  a  jacket,  according  to  the  size  of  the  child.  They 
should  be  placed  on  end,  in  a  pail  of  warm  water,  one  at  a  time 
as  they  are  used.  'No  salt  or  alum  should  be  used  to  hasten  the 
setting  of  the  plaster ;  in  fact,  if  such  aid  is  necessary  it  is  unfit 
for  use.  When  the  bubbles  have  ceased  to  rise  the  bandage  is 
squeezed  gently  until  no  water  drips  from  it,  and  the  loose 
threads  are  removed  from  the  ends. 

One  person  should  sit  behind  the  patient  and  one  in  front, 
while  the  third  may  hold  the  rope  and  check  the  swaying  of  the 
body.  The  one  who  sits  behind  the  patient  may  clasp  the  child's 
legs  between  his  knees  and  thus  assure  better  fixation  of  the 
pelvis.  The  pads  are  held  in  position  until  they  are  fixed  by  the 
plaster  bandages,  which  should  be  applied  with  a  slight  and  even 
tension. 

As  a  rule,  the  jacket  should  be  of  uniform  thickness  through- 
out. This  thickness  need  not  exceed  one-eighth  to  one-fourth  of 
an  inch,  and  it  may  even  be  lighter  in  certain  cases.  It  is  well 
to  begin  by  figure  of  eight  turns  about  the  waist  and  pelvis  with 
sufiicient  tension  to  bring  into  relief  the  pelvic  crests,  since  the 
pelvis  is  the  base  of  support;  and,  as  the  most  important  point 
for  counterpressure  is  the  upper  part  of  the  chest,  the  appliance 
should  be  made  especially  strong  and  resistant  at  this  point. 

During  the  application  of  the  jacket  it  should  be  rubbed  con- 
stantly in  order  that  the  different  layers  of  bandage  may  adhere 
to  one  another,  and  that  it  may  fit  the  projections  of  the  pelvis 
and  body  closely.  Meanwhile  the  attitude  of  the  patient  should 
be  carefully  watched,  in  order  to  prevent  lateral  inclination  of 
the  body.  It  is  often  possible  while  the  patient  is  suspended  to 
correct  the  deformity  still  further  by  backward  traction  on  the 
shoulders  and  forward  pressure  on  the  trunk  while  the  jacket 
is  hardening. 

When  the  jacket  is  nearly  firm  it  should  be  trimmed.  In 
many  instances  this  may  be  done  while  the  patient  is  in  the 


TUBEBCULOUS    DISEASE    OF    THE    SPINE. 


79 


swing,  but  if  he  is  fatigued  he  may  be  placed  in  the  recumbent 
posture. 

As  a  rule,  the  front  of  the  jacket  should  reach  from  the  upper 
margin  of  the  sternum  to  the  pubes;  behind,  from  about  the 
midline  of  the  scapulae  to  the  gluteal  fold ;  laterally,  it  should  be 
cut  away  sufficiently  to  prevent  chafing  of  the  arms;  and  on 
either  side  of  the  pubes  an  oval  section  is  cut  out,  to  allow  for 
the  flexion  of  the  thighs  in  the  sitting  posture.    Particular  atten- 

FiG.  41. 


The  jury-mast  and  tbe  anterior  support. 


tion  is  called  to  the  importance  of  making  the  jacket  as  long  as 
possible,  so  that  the  abdomen  may  be  contained  within  it  instead 
of  being  forced  out  beneath  its  lower  border  (Fig.  40).  After 
the  application  of  the  jacket  the  patient  should  remain  in  the 
recumbent  posture  for  at  least  half  an  hour  or  longer,  as  it  does 
not  become  absolutely  firm  for  several  hours.  The  shirt  is  then 
drawn  up  over  the  jacket  and  is  sewed  to  the  neck  portion;  this 
adds  much  to  neatness  and  cleanliness.  The  shirt  must  be 
drawn  tightly  about  the  neck,  in  order  to  guard  the  body  from 
the  crumbs  or  other  objects  that  may  fall  beneath  the  jacket, 


80 


OBTHOPEDIC    SUBGEBY. 


and  in  many  instances  a  special  protector  in  the  form  of  a  wide 
collar  bib  may  be  used  with  advantage. 

The  upper  and  lower  ends  of  the  cleansing  bandages  are 
joined  to  one  another  with  tape,  and  with  them  the  skin  is  care- 
fully rubbed  twice  daily.     When  soiled  they  may  be  replaced. 

It  may  be  mentioned  in  this  connection  that  even  the  slightest 
excoriation  or  irritation  of  the  skin  beneath  the  jacket  can  be 
detected  by  the  peculiar  odor.  Of  this  parents  should  be  in- 
formed, so  that  it  may  be  cut  down  and  the  source  of  the  irrita- 
tion removed  at  once.  With  ordinary  care  "  sores,"  the  bugbear 
of  the  plaster  jacket,  may  be  avoided  or  so  quickly  detected  that 
they  are  of  little  consequence. 

Fig.  42. 


The  jury-mfist. 


From  the  mechanical  standpoint  the  plaster  support  is  most 
satisfactory  in  the  treatment  of  disease  of  the  dorso-lumbar 
region,  its  efficiency  lessening  according  to  the  distance  from 
this  central  point. 

If  the  disease  is  above  the  tenth  dorsal  vertebra  it  is  well  to 
carry  the  plaster  bandages  about  the  neck  and  in  front  of  the 
shoulders  as  in  the  Calot  jacket  or  direct  backward  traction  on 
the  shoulders  may  be  made  by  means  of  the  anterior  shoulder 
brace  described  in  connection  with  the  spinal  brace  (Fig.  41)  ; 
this  may  be  attached  to  buckles  incorporated  in  the  plaster  or 
by  tapes  crossed  behind  the  shoulders.  Traction  applied  in 
this  manner  is  an  additional  fixation  for  the  spine  and  assures 
better  expansion  of  the  chest.  In  default  of  this  appliance  the 
shoulders  may  be  included  in  the  plaster  support. 

In  many  instances  a  head  support  is  required,  and  it  is,  of 


TUBEBCULOUS    DISEASE    OF    THE    SPINE. 


11 


course,  always  indicated  in  disease  of  the  upper  dorsal  and  cer- 
vical regions.  For  this  purpose  the  head  may  be  included  in 
the  plaster  support  or  a  jury-mast  or  a  posterior  splint  may  be 
employed. 

The  jury-mast  should  be  of  tempered  steel,  strong  enough  to 
hold  its  shape  under  the  tension  of  the  halter  (Fig.  42).  Its 
base  should  be  incorporated  firmly  in  the  jacket  below  the  seat 

Fig.  43. 


Illustrating  fixation  of  the  head  in  the  overextended  attitude. 


of  the  disease ;  it  should  be  long  enough  to  reach  well  above  the 
head,  and  the  crossbar  should  be  placed  directly  over  the  ears 
(Fig.  46). 

The  halter  should  be  applied  with  as  much  tension  as  can  be 
borne  comfortably  by  the  patient,  so  that  the  weight  of  the  head 
may  be  at  least  partly  supported.  The  straps  should  be  adjusted 
to  tilt  the  chin  slightly  upward,  the  aim  being  to  draw  the  head 
backward  and  thus  to  extend  the  spine.  In  disease  of  the  cer- 
vical region  the  crossbar  should  be  fixed  to  check  lateral  motion 
6 


OBTEOPEDIC   SUBGEBY. 


of  the  head,  but  this  is  unnecessaiy  when  it  is  at  a  lower  level. 
If  more  complete  fixation  of  the  head  is  desired,  or  if  the 
jurj-mast  is  ineffective,  an  appliance  similar  to  that  shown  in 
Fig.  44  mav  be  used.  This  consists  of  two  light  steel  bars,  in- 
corporated like  the  jury-mast  in  the  jacket,  and  adjusted  to  the 
neck  and  back  of  the  head.     Their  upper  extremities  are  joined 


Fig.  44. 


Fig.  4.5. 


A  fixation  support  for  the  head. 
This  may  be  used  with  the  brace  or 
with  the  jacket. 


Front  view  of  the  same  patient. 


by  a  band  of  light  steel  of  U-shape,  long  enough  to  reach  from 
ear  to  ear,  the  circumference  being  comiDleted  by  a  band  of  tape 
across  the  forehead.  In  certain  instances  additional  straps  may 
be  placed  beneath  the  chin  and  the  occiput,  as  in  Figs.  44  and 
45.  In  this  connection  it  may  be  stated  that  the  support  pro- 
vided by  the  jury-mast  is  only  effective  when  it  is  carefully  ad- 
justed and  constantly  watched.  In  most  instances,  therefore,  a 
rigid   apparatus,  though  less  comfortable,   is  to  be  preferred. 


TUBEECULOUS    DISEASE    OF    THE    SPINE. 


83 


If  the  jacket  is  carefully  fitted  to  the  pelvis  it  may  be  a  fairly 
efficient  support  even  if  the  disease  is  in  the  lower  lumbar  re- 
gion. If,  however,  the  symptoms  are  acute  with  accompanying 
spasm  of  the  flexors  of  the  thigh  it  should  be  extended  to  one  or 


Fig.  45. 


The  jacket  and  jury-mast  applied.     The  same  patient  is  shown  in   Fig.   33. 


both  knees   as   a  single  or   double   spica  according  to  the  in- 
dications. 

The  Calot  Jacket. — Calot  was  at  one  time  an  advocate  of  the 
immediate  correction  of  the  deformity  of  Pott's  disease,  a  treat- 
ment described  in  previous  editions  of  this  book.  Although  the- 
method  is  no  longer  used,  it  served  its  purpose  in  calling  atten- 
tion to  the  importance  of  more  effective  preventive  treatment,, 
and  it  has  further  been  demonstrated  that  the  deformity  may 
be  corrected  to  the  same  degree,  as  far  as  the  final  result  is  con- 
cerned, by  milder  methods.  One  of  these  is  the  convex  stretcher 
frame  in  recumbency,  and  another  is  the  Calot  jacket  in  ambu- 
latory treatment. 


84 


ORTHOPEDIC    SURGERY. 


The  essentials  of  the  Calot  support  are  fixation  of  the  neck 
and  shoulders  as  well  as  of  the  pelvis,  and  direct  pressure  over 
the  kyphosis,  the  front  of  the  jacket  having  been  cut  away  so 
that  the  trunk  may  be  forced  forward,  thus  straightening  the 
spine  as  a  whole,  and  in  some  degree  the  local  deformity. 


Fig.  47. 


Fig.  48. 


The   Calot  jacket  showing  the  appli- 
cation to  the  neck  and  shoulders. 


The   Calot   jacket    showing 
hooks. 


the   pad   and 


In  applying  the  support  the  patient  is  partly  suspended  in 
the  ordinary  manner.  If  the  head  is  to  be  included  a  special 
sling  must  be  used.  This  may  be  improvised  from  bandage 
material,  but  preferably  it  is  made  of  canvas.  It  should  be 
about  five  to  six  feet  in  length  and  two  and  a  half  inches  in 
width,  the  ends  are  sewed  together  making  when  it  is  passed 
over  the  cross  bar,  two  loops,  of  which  one  is  placed  about  the 


TUBERCULOUS    DISEASE    OF    THE    SPINE. 


85 


chin  and  the  other  beneath  the  occij)ut.  These  are  attached  to 
one  another  by  safety  j)ins  above  the  ears.  To  the  posterior  loop 
a  similar  band  about  three  and  a  half  feet  in  length  is  sewed. 
This  when  carried  behind  the  occiput  and  attached  to  the  cross 
bar  holds  the  head  firmly  in  the  desired  position  if  it  is  to  be 
included  in  the  support.  A  close  fitting  shirt  with  a  high  neck 
and  sleeves  is  worn.  The  protecting  pads  are  then  applied  in 
the  usual  manner  and  a  band  of  felt  is  placed  about  the  neck. 

Fig.  49. 


The  Calot  jacket  showing  the  thick  block  of  wood  UBed  for  pressure  over 
the  felt  pads.  For  this  detail  in  the  pressure  appliance  I  am  indebted  to  Dr. 
G.  E.  Bennett. 


In  addition  the  front  of  the  thorax  is  covered  with  a  layer  of 
cotton  batting  about  one  inch  in  thickness.  The  arms  are  sup- 
ported at  a  right  angle  to  the  trunk  and  the  jacket  is  con- 
structed, if  the  disease  is  of  the  lower  dorsal  region,  to  include 
the  neck  and  shoulders.  As  a  part  is  to  be  cut  away  it  must 
be  made  much  thicker  than  the  ordinary  jacket,  especially  over  the 


86 


OBTHOPEDIC    SUEGEEY. 


shoulders,  on  the  lateral  borders  of  the  chest  and  about  the  de- 
formity. Calot  constructs  the  jacket  with  layers  of  crinoline 
previously  cut  in  patterns,  which  are  then  saturated  with  liquid 
plaster  mixture,  but  those  accustomed  to  the  roller  bandages  will 
prefer  them,  strengthening  the  jacket  by  reverses  in  the  usual 
manner. 

When  the  jacket  is  sufficiently  firm  the  patient  is  placed 
upon  the  back  and  a  small  triangular  opening  is  cut  over  the 

Fig.  50. 


The  Calot  jacket  showing  the  head  support  and  hooks. 

chest  through  which  the  thoracic  pad  is  removed,  so  that  respi- 
ration may  not  be  constrained.  The  following  day,  or  when  the 
jacket  is  thoroughly  dry,  the  front  is  cut  away  as  illustrated  in 
the  pictures.  Another  opening  is  made  in  the  back  to  thoroughly 
expose  the  area  of  the  disease.     Vaseline  is  then  applied  to  the 


TUBEECULOUS    DISEASE    OF    THE    SPINE.  87 

skin  and  pads  of  cotton  one  after  the  other  are  forced  into  the 
opening  to  the  point  of  toleration,  with  the  aim  of  pressing  the 
trunk  forward  and  flattening  the  projection.  These  pads  are 
held  in  place  by  turns  of  plaster  bandage  or  bj  adhesive  plaster. 
The  procedure  is  repeated  at  intervals  of  several  weeks,  the 
pressure  if  j^ossible  being  increased. 

A  more  accurate  adjustment  of  the  corrective  force  and  one 
that  permits  inspection  of  the  spine  and  thus  lessens  the  danger 
of  pressure  sores,  is  as  follows :  the  pads  are  made  of  thick  felt 
arranged  to  press  on  either  side  of  the  spinous  processes.  Over 
them  is  placed  a  thick  piece  of  wood  of  the  exact  size  of  the 
opening.  Pressure  is  made  by  two  firm  bands  of  tape  buckled 
to  metal  hooks  fixed  to  the  lateral  margins  of  the  jacket. 

If  the  disease  is  of  the  upper  third  of  the  spine  the  head 
should  be  supported.  The  sling  is  adjusted  to  hold  the  head 
in  a  jDosition  of  slight  extension.  The  shirting  is  drawn  over 
the  head,  an  opening  having  been  cut  for  the  face.  The  neck, 
chin  and  occiput  are  protected  with  felt  or  cotton  and  the  plaster 
is  applied  about  the  head ;  the  sling  is  then  removed  and  the 
support  cut  to  the  shape  shown  in  the  illustration,  Fig.  50. 
The  shirting  is  afterwards  sewed  in  the  usual  manner. 

The  Calot  jacket  is  difiicult  to  adjust,  but  it  is  far  more 
effective  than  any  other  form  of  ambulatory  support. 

The  Application  of  the  Jacket  in  the  Recumbent  Posture. — The 
jacket  may  be  applied  while  the  patient  lies  extended  in  the 
prone  posture,  by  the  hammock  method  suggested  by  Davy,  of 
London. 

A  long  narrow  strip  of  cotton  cloth  is  passed  under  the  shirt 
and  is  drawn  tight  enough,  by  means  of  a  pulley  or  by  manual 
traction,  to  support  the  trunk  in  the  proper  attitude,  preferably, 
of  course,  in  overextension.  An  opening  is  cut  for  the  face,  and 
if  advisable,  traction  may  be  made  on  the  arms  and  legs  of  the 
patient.  The  bandages  are  then  applied  in  the  ordinary  man- 
ner, after  which  the  cloth  may  be  cut  short  at  one  end  and  re- 
moved. 

This  method  is  of  senace  in  the  treatment  of  weak  or  para- 
lyzed patients,  but  the  adjustment  is  somewhat  less  satisfactory 
than  by  the  ordinary  method  in  that  the  fixation  of  the  thorax 
is  less  accurate.  The  jacket  may  be  applied  in  the  supine 
posture  by  means  of  the  Goldthwait  apparatus.  This  may  be 
employed  also  in  the  routine  application  of  the  plaster  jacket. 


88  OBTEOPEDIC    SUBGEBY. 

It  consists  essentially  of  a  support  (Fig.  51)  carrying  on  its 
upper  extremities  two  thin  strips  of  perforated  metal.  To  these 
strips  felt  is  attached,  forming  pads  similar  to  those  used  on  the 
back  brace.  The  patient  is  then  placed  with  his  back  resting  on 
the  pads  at  the  seat  of  the  disease.  The  buttocks  and  the  head 
are  allowed  to  sink  downward  to  the  point  of  toleration ;  thus  an 
extending  force  is  exerted  on  the  spine.  The  plaster  bandages 
are  then  applied  in  the  usual  manner  about  the  body  on  either 
side  of  the  support.     When  it  is  completed  the  patient  is  lifted 

Fig.  51. 


The  application  of  the  jacket  in  the  recumbent  posture  by  means  of  the  Gold- 
thwait  appliance ;  A,  the  support,  similar  to  that  upon  which  the  patient  is 
lying;  B,  two  thin  bands  of  steel,  similar  to  those  used  in  the  Taylor  brace. 


from  the  support,  the  pads  being  included,  of  course,  in  the 
jacket.  An  opening  remains  at  this  point  that  may  be  closed  by 
an  additional  bandage. 

Other  supports  of  a  similar  nature  are  in  use,  but  as  they  do 
not  differ  from  it  in  principle  a  detailed  description  is  unneces- 
sary (Figs.  52  and  53). 

If  the  deformity  is  of  recent  origin  it  may  be  actually  cor- 
rected by  the  leverage  exerted,  but  in  many  instances  the  hyper- 
extension  takes  place  in  the  unaffected  parts  of  the  spine,  par- 


TUBEECULOUS    DISEASE    OF    THE    SPINE. 


89 


ticularly  in  the  lumbar  region.  Thus  the  correction  is  ap- 
parent rather  than  actual.  In  order  to  prevent  this  and  to  exert 
more  effective  leverage  on  the  deformity  Goldthwait  uses  the 
apparatus  illustrated  in  Fig.  54. 


Fig.  52. 


R.  Tunstall  Taylor's  apparatus  for  the  application  of  the  plaster  jacket  in  the 
recumbent  posture,  consisting  of  an  adjustable  back  support  and  pelvic  rest  con- 
nected by  a  sliding  bar.      (See  Fig.  53.) 

The  patient  lies  on  two  malleable  steel  bars  fitted  to  the  lum- 
bar region  reaching  only  to  the  apex  of  the  deformity.  The 
plaster  bandages  forming  the  lower  part  of  the  jacket  having 
•been  applied  the  upper  portion  of  the  trunk  is  allowed  to  sink 
downward  to  the  point  of  toleration  and  the  jacket  is  then  com- 
pleted. The  steel  bars  which  have  prevented  the  upward  arch- 
ing of  the  lumbar  region  of  the  spine  are  then  withdrawn.     The 

Fig.  53. 


The  Taylor  appliance  in  use,  showing  the  hyperextension  of  the  spine.  The 
plaster  jacket  having  been  applied,  the  back  rest  is  removed  by  pressing  the 
bandages  from  side  to  side  or  by  enlarging  the  opening.  If  desirable,  the  de- 
fect is  then  concealed  by  a  turn  of  plaster  bandage. 


Metzger  apparatus,  of  which  that  last  described  is  an  adaptation, 
which  jDermits  longitudinal  traction  as  well  as  direct  leverage, 
is  shown  in  Fig;.  55. 


90 


OBTHOPEDIC    SUEGEEY. 


The  Application  of  the  Jacket  to  Patients  Who  Have  Been  Treated 
on  the  Stretcher  Frame. — A  satisfactory  method  of  applying  a 
plaster  jacket  to  young  subjects,  when  the  deformity  has  been 

Fig.  54. 


Goldthwaif s  portable  frame  for  applying  the  plaster  jacket. 

corrected  in  whole  or  in  part  by  recumbency  on  the  frame  in  the 
overextended  position,  is  the  following :  The  patient  is  suspended 
face  downward  in  the  horizontal  position  by  two  assistants,  one 

Fig.  55. 


The  plaster  jacket  applied  in  supine  posture  by  means  of  the  Metzger- 
Goldthwait  apparatus. 

holding  the  arms  and  the  other  the  thighs ;  thus,  a  certain 
amount  of  traction  is  exerted,  while  the  weight  of  the  body  tends 
to  overextend  the  spine. 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  91 

In  this  attitude  a  jacket  is  quickly  applied,  and  the  child  is 
at  once  replaced  upon  the  frame,  which  has  been  protected  bv  a 
rubber  sheet  (Fig.  56).     The  plaster  jacket,  during  the  harden- 

riG.  56. 


The  stretcher  frame  on   which   the  patient  is  replaced  while  the  jacket  is 

hardening. 

Fig.  57. 


Jacket  applied  by  the  stretcher  method,  showing  the  depressions  on  either  side 
caused   by   the   frame   pads. 

ing  process,  must  conform  to  the  habitual  posture  of  recumbency. 
The  pressure  pads  of  the  frame  indent  the  bandage  on  either 
side  of  the  spinous  processes  (Fig.  57),  and  thus  afford  better 


92  ORTHOPEDIC    SUEGEBY. 

support  and  fixation.  This  is  a  very  satisfactory  method  of  ap- 
plying the  jacket  in  this  class  of  cases,  because  it  is  not  neces- 
sary to  retain  the  child  in  an  uncomfortable  position  while  the 
support  is  hardening,  and  because  accuracy  of  adjustment  in 
the  best  possible  attitude  is  assured. 

For  the  routine  application  of  the  plaster  jacket  vertical  sus- 
pension is  to  be  preferred,  because  in  this  more  natural  attitude 
the  support  may  be  more  accurately  and  comfortably  adjusted. 
The  hammock  method  and  that  just  described  are  of  particular 
service  in  the  treatment  of  young  subjects.  The  supine  posture 
may  be  selected  with  advantage  when  the  spine  is  sufiiciently 
flexible  at  the  seat  of  disease  to  permit  a  certain  degree  of  cor- 
rection or  if  the  patient  is  weak  or  timid  or  paralyzed. 

As  a  rule,  a  jacket  may  be  worn  for  two  months,  although  not 
infrequently  it  may  remain  for  six  months,  or  even  longer,  and 
yet  be  fairly  efficient.  Usually  one  jacket  is  removed  and  an- 
other applied  on  the  same  day,  but  if  the  skin  is  at  all  sensitive 
it  is  well,  after  the  washing  and  powdering,  to  reapply  the  old 
jacket,  closing  it  with  adhesive  plaster,  and  allow  an  interval  of 
a  few  days  before  applying  the  permanent  one. 

The  Plaster  Corset. — In  the  stage  of  recovery  the  jacket  may  be 
replaced  by  a  corset.  A  jacket,  made  and  trimmed  as  already 
described,  is  cut  down  the  centre  and  removed  from  the  body. 
It  is  carefully  readjusted  to  its  former  shape,  bandaged  with  the 
cut  surfaces  in  close  apposition,  and  is  thoroughly  dried  or 
baked. 

All  wrinkles  are  then  cut  away  from  the  inner  surface,  and 
extra  padding  is  applied  if  necessary ;  the  shirt  is  drawn  tightly 
about  the  borders  of  the  jacket  and  strips  of  leather  provided 
with  hooks  are  sewed  in  front  so  that  it  may  be  laced  like  an 
ordinary  corset.  It  may  be  removed  from  time  to  time  to  allow 
for  bathing,  but  it  should  always  be  removed  and  reapplied  while 
the  patient  is  suspended  or  in  the  recumbent  position. 

The  corset  is  sometimes  used  in  place  of  the  jacket  during  the 
active  stage  of  the  disease,  but  it  is  less  effective,  since  the  re- 
peated stretching  during  removal  and  reapplication  weakens 
the  appliance  and  impairs  the  accuracy  of  adjustment.  In  addi- 
tion, one  of  the  strongest  arguments  in  favor  of  the  use  of  plaster 
of  Paris,  that  treatment  is  under  the  control  of  the  surgeon,  is 
nullified. 

Corsets  of  Other  Material  than  Plaster  of  Paris. — Corsets  of 
wood,  leather,   paper,  poroplastic  felt,  celluloid  or  aluminium 


TUBEBCULOUS    DISEASE    OF    THE    SPINE. 


93 


are  sometimes  used.     TLiese  are  constructed  on  a  plaster  cast  of 
the  body,  an  accurately  fitting  jacket  being  used  as  a  mould. 

Such  corsets  have  certain  advantages  of  durability  and  ele- 
gance, but  none  of  them  has  the  accuracy  of  fit  of  the  plaster-of- 
Paris  corset,  which  is  moulded  directly  on  the  body.  Corsets  of 
this  class  are  usually  somewhat  expensive,  and  on  that  account 
are  often  worn  after  they  are  outgrown  or  when  they  no  longer 
fit  the  patient.  Their  use  is  practically  limited  to  the  stage  of 
recovery  or  for  other  affections  than  Pott's  disease. 

The  Back  Brace. — The  spinal  brace,  or  spinal  assistant,  as  the 
original  appliance  of  Dr.  C.  F.  Taylor  was  called,  consists 
essentially  of  two  steel  bars  that  are  applied  on  either  side  of  the 
spinous  processes  from  the  top  to  the  bottom  of  the  spine.  At 
the  seat  of  the  disease  pads  are  placed  to  provide  for  greater 
pressure  and  fixation,  and  to  form  a  fulcrum  over  which  the 
spine  may  be  straightened  or  held  erect,  when  the  two  extremi- 
ties of  the  brace  are  firmly  attached  to  the  pelvis  and  to  the 

shoulders.  The  attachment  at  the 
lower  end  is  made  by  means  of  a 
pelvic  band  of  sheet  steel  (gauge 
18)  from  one  and  a  half  to  two 
inches  in  width,  long  enough  to 
reach  from  one  iliac  spine  to  the 
other;  it  is  placed  as  low  as  possi- 
ble on  the  pelvis ;  in  other  words, 
just  above  the  upper  extremities  of 
the  trochanters.  To  this  the  up- 
rights  are  firmly   attached   at   an 

Fig.  59. 


Fig.  58. 


The  Taylor  back  brace.     ( H.  L.  Taylor. ) 


The  Taylor  chest  piece.  Two  tri- 
angular pads  of  hard  rubber  connected 
Dy  a  bar. 


94 


ORTHOPEDIC    SUBGEBY. 


interval  of  from  one  and  a  quarter  to  one  and  three-quarter 
inches  from  one  another,  so  that  the  spinous  processes  may  pass 
between  them,  while  pressure  is  made  on  the  lateral  masses  of 
the  vertehrse.  The  uprights  are  made  of  varying  strength,  ac- 
cording to  the  age  of  the  patient,  usually  about  one-half  an  inch 
in  width  (of  gauge  8  to  12)  and  of  such  quality  of  steel  that, 
although  unyielding  to  the  strain  of  use,  it  may  be  readily  bent 
by  wrenches,  and  thus  accurately  adjusted  to  the  back.     The  up- 


FiG.  60. 


Fig.  61. 


/m^.-% 


Backward  traction  on  the  shoulder  fixes 
the  upper  dorsal  region. 


The  anterior  shoulder  brace  and  its 
attachment. 


rights  reach  to  the  root  of  the  neck,  or  to  about  the  level  of  the 
second  dorsal  vertebra ;  from  this  point  two  short  arms  of  metal 
project  forward  and  outward  on  either  side  of  the  neck,  reaching 
to  about  the  middle  of  the  clavicles.  To  these,  padded  shoulder 
straps  are  attached,  which  pass  through  the  axillae  to  a  crossbar 
on  the  back  brace ;  thus  downward  pressure  on  the  shoulders  is 
avoided  and  increased  leverage  is  assured  (Fig.  62). 

Opposite  the  area  of  disease  two  strips  of  thin  steel  about 
three  inches  in  length  are  fixed  ;  these  are  slightly  wider  than  the 
uprights  and  are  perforated  for  the  attachment  of  the  pressure 

f 


^ 


TUBERCULOUS    DISEASE    OF    TEE    SPINE. 


95 


pads,  which  may  be  made  of  layers  of  canton  flannel  or  felt,  or 
unyielding  material,  such  as  leather  or  hard  rubber,  may  be  used 
instead.  The  pads  should  project  from  a  quarter  to  a  half-inch 
in  front  of  the  uprights  in  order  that  firm  and  constant  pres- 


FiG.  62. 


The  Taylor  brace  and  head  support  applied  for  disease  of  the  upper  dorsal 

region. 


sure,  to  the  extent  that  the  skin  will  tolerate,  may  be  made  at 
the  seat  of  disease  (Fig.  58). 

In  measuring  for  this  brace  the  patient  is  placed  in  the  prone 
posture  and  a  tracing  of  the  outline  of  the  back  is  made  by 
means  of  the  lead  tape.  T]^is  outline  may  be  cut  in  cardboard 
and  fitted  to  the  back ;  in  fact,  if  the  mechanic  is  unfamiliar 
with  the  work,  each  part  of  the  brace,  uprights,  pelvic  band,  etc., 
may  be  cut  in  cardboard  and  attached  to  one  another  to  serve 
as  a  model.  Be'fore  the  brace  is  finished  it  should  be  applied  to 
the  back  and  should  be  adjusted  carefully  by  means  of  wrenches. 


96 


OBTHOPEDIC  JSUBGEBT. 


The  pelvic  band  and  the  parts  that  come  into  direct  contact  with 
the  skin  are  usually  covered  with  leather,  or,  in  the  treatment 
of  young  chidren,  with  rubber  plaster  and  canton  flannel  to 
prevent  rusting. 

If  the  brace  is  applied  before  the  stage  of  deformity  it  should 
follow  the  exact  shape  of  the  spine,  but  if  deformity  is  present, 


Fig.  63. 


Fig.  64. 


The  Taylor  brace  and  head  support 
applied  to  the  patient  shown  in  Fig. 
69. 


The  Taylor  brace  with  jury-mast. 


particularly  in  disease  of  the  thoracic  region,  it  should  be  made 
somewhat  straighter,  in  order  to  permit  a  gradual  correction  of 
the  compensatory  lordosis  in  the  lumbar  region,  and  for  in- 
creased leverage  above  the  deformity.     As  has  been  stated,  a 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  97 

certain  degree  of  recession  of  deformity  can  be  obtained  by 
rest  in  the  horizontal  position,  and  if  practicable  this  improved 
contour  should  be  attained  before  the  brace  is  applied.  The 
apparatus  is  held  in  place  by  an  ''apron"  (Fig.  63),  which 
covers  the  chest  and  abdomen,  to  which  straps  are  attached. 
Ordinarily  this  is  made  of  strong  linen  or  cotton  cloth,  but  a 
canvas  front  shaped  accurately  to  the  body  and  strengthened 

Fig.  65. 


The  Taylor  back  brace  and  head  support   combined  with   the  Whitman   anterior 

support. 

with  whalebone,  is  a  more  comfortable  and  efficient  support.  In 
applying  the  brace  the  pelvic  band  is  first  attached  to  the  apron, 
then  the  straps  in  order,  from  below  upward,  and,  finally,  the 
shoulder  straps.  Each  strap  is  tightened  until  the  brace  is 
firmly  fixed  in  proper  position.  When  a  brace  is  properly  ap- 
plied and  properly  fitted  it  holds  its  place  by  friction,  but  whet 
7 


98 


OBTEOPEDIC    SURGEBY. 


the  disease  of  the  lower  lumbar  region,  or  if  the  brace  has  a 
tendency  to  upward  displacement  perineal  straps  should  be  used 
to  hold  the  pelvic  band  firmly  in  its  place  (Fig.  58).  At  first 
the  brace  is  removed  once  a  day  in  order  to  wash  and  powder 
the  back,  the  same  care  being  observed  in  moving  the  child  as 
in  the  treatment  by  the  frame ;  but  when  the  skin  has  become 
accustomed  to  the  pressure  the  brace  should  be  removed  only  at 


Fig.  66. 


Fig.  67. 


The  anterior  shoulder  brace. 


The  scapular  pads. 


infrequent  intervals,  and,  thus,  if  desirable,  only  under  the 
supervision  of  the  surgeon. 

This  description  indicates  the  essential  qualities  of  the  back 
brace.  It  has  been  modified  in  various  ways ;  for  example.  Dr. 
Taylor  long  since  discarded  the  straight  pelvic  band  in  favor 
of  one  of  a  U-shape  (Fig.  58).  This  makes  the  brace  somewhat 
lighter  and  relieves  the  sacrum  from  pressure,  but  it  does  not 
add  to  its  effectiveness.  The  efficiency  may  be  increased,  how- 
ever, by  improving  the  attachment  at  its  upper  extremity,  as 
is  illustrated  in  Fig.  59,  in  which  two  triangular  pads  of  hard 
rubber  connected  by  a  metal  bar  are  employed. 

This  is  an  improvement  on  the  simple  shoulder  straps  of  the 
original  brace,  but  it  does  not  provide  the  quality  of  support  and 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  99 

fixation  that  is  desirable  when  the  disease  is  of  the  upper  or 
middle  segment  of  the  thoracic  region.  In  such  cases  the  upper 
part  of  the  chest  is  flattened,  the  inclination  of  the  ribs  is  in- 
creased, and  the  shoulders  droop  forward,  carrying  with  them 
the  scapulae.  Thus,  the  weight  and  the  strain  of  the  motion  and 
use  of  the  arms  tend  to  increase  the  deformity. 

In  health  direct  forward  or  reaching  movements  of  the  arms 
are  always  accompanied  by  an  increase  in  the  posterior  curva- 
ture of  the  dorsal  spine.  On  the  other  hand,  if  the  shoulders 
are  drawn,  backward  and  held  in  this  attitude,  the  curvature  of 
the  spine  is  lessened  and  the  chest  is  elevated  and  expanded 
(Fig.  60). 

In  the  treatment  of  disease  of  the  upper  dorsal  region  it 
should  be  the  aim,  in  the  application  of  a  brace,  to  follow  this 
indication  and  to  apply  pressure  directly  upon  the  extremities 
of  the  shoulders  to  assure  the  greatest  possible  fixation  of  the 
spine  and  to  restrain  the  movements  of  the  arms  that  tend  to 
increase  the  deformity. 

The  diagrams  illustrated  in  Fig.  61  show  how  such  support 
may  be  applied.  Two  saucer-shaped  plates  of  hard  rubber  or 
padded  metal  (Fig.  65)  cover  the  heads  of  the  humeri  and  are 
joined  by  a  rigid  bar  of  steel,  which  passes  across  but  does  not 
touch  the  chest.  On  the  back  brace  are  placed  two  triangular 
pads  of  similar  construction,  which  cover  and  press  upon  the 
scapulae.  These  pads  are,  however,  not  essential  and  are  often 
omitted.  The  back  brace  is  applied,  the  shoulders  are  then 
drawn  backward  and  the  shoulder-cups  are  firmly  attached  by 
straps  to  the  neck  bars  of  the  brace  above,  and  by  axillary  bands 
below  in  the  usual  manner.  By  this  means  the  thorax  is  ele- 
vated and  the  spine  is  more  effectively  fixed,  while  direct  move- 
ment of  the  arms  forward  is  made  impossible.  It  would  seem 
that  such  restraint  would  be  irksome  to  the  patient,  but  in  an 
extended  use  of  the  apparatus  this  has  never  caused  complaint. 
In  many  instances,  even  when  the  disease  is  as  low  as  the  tenth 
dorsal  vertebra,  it  may  be  used  with  advantage,  but  it  is 
especially  indicated  when  the  disease  is  in  the  neighborhood  of 
the  seventh  dorsal  vertebra.  In  connection  with  the  shoulder 
brace  it  is  usually  advisable  to  apply  a  support  beneath  the  chin 
to  prevent  the  forward  inclination  of  the  neck  and  to  tilt  the 
head  somewhat  backward.  A  very  simple  and  inoffensive  sup- 
port of  this  character  is  a  loop  of  steel  surrounding  the  neck  and 
attached  by  screws  to  a  back  bar  on  the  brace  (Fig.  68).     If  a 


100 


OBTHOPEDIC    SURGE E¥. 


Fig.  69. 


more  efficient  brace  is  required,  as  when  the  disease  is  of  the 
upper  dorsal  or  cervical  regions,  the  Taylor  head  support  should 
be  used.  This  is  an  oval  ring  of  steel  which  may  be  clasped  about 
the  neck  by  means  of  a  lateral  hinge.  On  the  front  a  cup  of 
hard  rubber  supports  the  chin  and  behind  the  ring  fits  upon  an 
upright  pivot  that  may 
be  raised  or  lowered 
upon  a  crossbar  on  the 
upper  part  of  the  brace  ; 
free  lateral  motion  is 
allowed,  or  it  may  be 
checked  by  means  of  a 
screw  (Fig;.  62V 

Fig.  68. 


The  loop  head  suppui't. 


Disease  of  the  middle  cervical  region,  show- 
ing the  deformity  and  attitude.  This  patient 
had  been  paralyzed  for  one  year  before  treat- 
ment was  begun.      (See  Fig.  63.) 


If  absolute  fixation  of  the  head  is  indicated,  as  in  disease  at 
or  near  the  occipitoaxoid  region,  two  steel  uprights  may  be  at- 
tached to  the  back  of  the  ring ;  these  are  bent  to  fit  the  posterior 
and  lateral  aspect  of  the  head  closely,  and  a  band  of  webbing 
is  passed  from  one  upright  to  the  other  and  about  the  forehead. 

In  applying  the  support  the  chin  should  always  be  tilted 
slightly  upward  in  order  to  throw  the  weight  of  the  head  back- 
ward (Fig.  63).     The  adjustment  of  the  head  support  is  made 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  101 

easier  if  the  pivot  is  attached  to  the  upright  hj  means  of  a 
ball-and-socket  joint  (Shaffer)  (Fig,  62)  that  may  be  regulated 
by  a  screw  and  key;  this  arrangement  is  of  service  when  the 
head  is  distorted,  but  it  is  by  no  means  necessary. 

When  the  Taylor  head  support  or  similar  appliance  is  used 
the  greater  part  of  the  pressure  is  sustained  by  the  chin,  which 
may,  after  a  time,  undergo  an  unsightly  recession.  It  may  be  of 
advantage,  therefore,  in  such  cases,  and  particularly  when  re- 
straint of  the  motion  of  the  neck  is  desirable,  to  transfer  this 
pressure  to  the  forehead  and  occiput  by  extending  the  back  bars 
upward  over  the  back  of  the  head  (Fig.  43). 

A  jury-mast  may  be  used  to  support  the  head  also,  its  adjust- 
ment as  described  in  connection  with  the  plaster  jacket  (Fig.  64). 

Comparison  of  the  Two  Forms  of  Ambulatory  Support.. — The  most 
severe  criticisms  of  the  jacket  have  been  made  by  those  un- 
familiar with  its  use,  on  theoretical  grounds  rather  than  from 
actual  observation.  While  it  is  apparent  that  there  are  certain 
objections  to  the  support,  yet  experience  has  shown  that  when  it 
is  applied  in  a  proper  manner  under  projier  conditions  it  is  a 
thoroughly  reliable,  efficient,  and  often  indispensable  means  of 
treatment.  Indeed,  it  may  be  stated  that  by  means  of  the 
various  forms  of  support  that  may  be  constructed  of  plaster  of 
Paris  it  is  possible  to  treat  successfully  nearly  every  case  of 
Pott's  disease  without  the  aid  of  the  professional  brace-maker. 

It  is  evident  that  under  certain  conditions  a  fixed  support 
must  be  inferior  to  the  adjustable  brace,  in  early  childhood  for 
example,  when  the  pelvis  is  undeveloped.  Again,  when  the 
disease  is  low  down,  at  or  near  the  lumbosacral  junction,  the 
lower  border  of  the  jacket  does  not  hold  the  pelvis  with  sufficient, 
security  to  provide  the  proper  support.  In  the  upper  dorsal 
region  the  attachments  for  accurate  fixation  may  be  adjusted 
more  readily  to  the  brace,  and  in  disease  of  the  cervical  region 
the  metallic  head  support  is  to  be  preferred  to  the  halter  of  the 
jury-mast,  for  the  reason  that  it  cannot  be  removed  by  the 
patient.  The  traction  of  the  jury-mast  is  very  effective  when 
properly  used,  and  particularly  so  when  painful  distortion  of 
the  neck  is  present,  but  the  tension  on  the  straps  is  rarely  con- 
stant, and  thus  it  loses  in  efficiency.  A  rigid  support  is,  of  course, 
preferable  in  the  disease  of  the  atloaxoid  region.  The  Calot 
support,  though  cumbersome  and  somewhat  difficult  of  adjust- 
ment, is  perhaps  the  most  efficient  means  of  treatment  of  disease 
of  the  upper  region  of  the  spine.  It  is  of  course  least  satis- 
factory during  the  warm  months. 


102 


OETSOPEDIO  SUEGEBY. 


The  jacket  is  most  serviceable  in  the  region  from  the  tenth 
dorsal  to  the  second  lumbar  vertebra.  It  is  not  only  effective, 
but  it  is  often  a  more  comfortable  support  than  the  spinal  brace. 
It  is  more  satisfactory  when  lateral  deviation  of  the  spine  is 
present,  and  from  the  clinical  standpoint  it  is  often  more  effica- 
cious in  relieving  pain  in  this  region  when  the  disease  is  at 
all  acute.  One  may  conclude,  then,  that  each  form  of  sup- 
port may  be  used  according  to  the  indications.  The  absolute 
control  of  the  treatment,  assured  by  the  use  of  the  plaster  jacket, 
will  often  overbalance  the  claims  of  the  brace. 

Other  Forms  of  Support.- — In  certain  cases  of  disease  of  the 
lower  lumbar  region  it  may  advisable  to  restrain  the  move- 
ments of  the  thighs,  although  ordinarily,  when  this  is  necessary, 
ambulation  should  be  discontinued.  Such  restraint  may  be 
attained  by  making  the  back  bars  of  the  brace  stronger  and 
extending  them  down  the  thighs  to  the  knees  like   a  double 

Thomas  hip  brace. 

Fig.  70. 


The  Thomas  collar  of  leather  stufEed  with  cotton.      (Ridlon  and  Jones.) 

Fig.  71. 


The  Thomas  collar  for  permanent  use.  A  piece  of  thin  sheet  metal  is  cut 
wide  enough  to  reach  from  the  sternum  to  the  chin,  and  from  the  back  of  the 
neck  to  the  base  of  the  occiput.  The  edges  are  turned  out  and  the  whole, 
properly   covered  with   felt   and  fitted.      (Ridlon  and  Jones.) 

If  the  jacket  is  used  it  may  be  extended  to  a  single  or  double 
spica  for  the  same  purpose  as  has  been  mentioned.  Such  appli- 
ances are  useful  when  psoas  spasm  and  "  cramp  "  are  trouble- 
some symptoms. 

In  disease  of  the  cervical  region  a  certain  amount  of  support 
and  fixation  may  be   obtained  by   collars   of  poroplastic  felt, 


TUBEBCULOUS    DISEASE    OF    THE    SPINE. 


103 


plaster  of  Paris,  or  other  material.  The  Thomas  collar  (Figs. 
70  and  71)  is  the  best  of  this  type  of  support,  but  none  of  them 
is  thoroughly  efficient  unless  used  with  a  brace  to  control  the 
larger  movements  of  the  spine.  They  are  useful  in  emergencies, 
but  they  are  not  often  required  when  proper  braces  can  be 
obtained. 

In  the  final  stage  of  treatment,  the  Knight  brace,  a  light  steel 
frame  with  corset  front,  may  be  used  (Fig.  74)  or  a  long  corset 
similar  to  that  ordinarily  worn  by  women,  but  strengthened  by 
the  insertion  of  light  steel  bars,  may  be  sufficient. 


Fig.  72. 


The  Thomas  collar  applied.      (Ridlon  and  Jones.) 

Many  other  forms  of  apparatus  of  greater  or  less  merit  might 
be  described,  but  space  has  permitted  only  a  detailed  account  of 
three  forms  that,  it  would  seem,  best  represent  the  essential 
principles  involved  in  the  treatment  of  Pott's  disease. 

The  Principles  of  Treatment  in  Their  Practical  Application. — The 
effect  of  treatment  must  be  estimated  not  simply  by  its  relief 
of  the  symptoms  of  the  disease,  since  deformity  may  increase 
in  spite  of  the  apparent  well-being  of  the  patient,  but  it  must 
be  selected  and  continued  or  changed  with  the  aim  of  com- 


104 


OETHOPEDIC    SUEGEEY. 


bating   ultimate    defonnitT,    and    on    this    standard    success    or 
failure  must  be  determined. 

Indications  for  Treatment  by  Recumbency. — As  lias  been  stated 
already,  the  most  important  influence  toward  deformity  is 
the  force  of  gravity ;  therefore,  horizontal  fixation  in  overexten- 
sion is  the  most  efficient  means  of  preventing  deformity,  and  of 
assuring  the  rest  that  favors  repair. 

Fig.  73. 


Cervical   Opistbotonos. 

It  is  indicated  as  the  routine  treatment  in  infancy  and  in 
early  childhood  up  to  the  age  of  four  years  at  least. 

In  many  instances  absolute  recumbency  may  not  be  required, 
Imt  the  period  of  activity  must  be  carefully  regulated,  and  must 
be  discontinued  when  there  is  evidence  of  discomfort  or  weak- 
ness or  pain.  If  the  period  of  activity  must  be  short,  it  should 
be  passed  in  the  open  air.  The  passive  attitude  of  sitting, 
although  less  strain  is  thrown  upon  the  spine  than  during 
activity,  may  be  even  worse  for  the  patient ;  thus,  the  reclining 
or  semi-reclining  posture  should  be  assumed  as  a  rule,  when  the 
child  is  in  the  house,  at  least  during  the  active  stage  of  the 
disease.  Even  if  the  spine  apj^ears  to  be  perfectly  supported, 
the  time  spent  in  bed  should  be  long,  and  a  period  of  rest  in  the 
middle  of  the  dav  should  be  enforced. 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  105 

The  arguments  in  favor  of  horizontal  fixation  in  early  child- 
hood do  not  apply  to  disease  in  the  adult.  At  this  age  the 
structure  of  the  spine  is  resistant,  and  deformity  is  little  to  be 
feared,  while  such  confinement  would  be  irksome  and  impracti- 
cable ;  thus,  local  support,  supervision,  and,  if  possible,  a  change 

Fig.  74. 


The   Knight  brace   with   the  back   bars  prolonged   to  support   the  head. 

of  climate  must  be  the  treatment  of  selection  for  the  adolescent 
or  adult. 

In  the  middle  period  of  childhood,  from  the  fifth  to  the  tenth 
year,  horizontal  fixation  is  the  treatment  for  emergencies ;  for 
paralysis,  for  abscess,  for  dangerous  disease  of  the  atlo-axoid 
region,  for  progressive  deformity,  and  for  pain  that  cannot  be 
relieved  by  the  ordinary  means. 

Special  Indications  for  Treatment  of  Diseases  of  the  Differ- 
ent Regions  of  the  Spine. — In  the  selection  of  treatment,  and 
in  the  general  management  of  Pott's  disease,  each  region  of  the 
spine  must  be  judged  by  itself,  since  in  each  there  are  special 
difficulties  to  be  met,  and  complications  to  be  feared  that  may 
influence  the  prognosis  and  lead  to  modifications  of  the  routine 
of  treatment. 


106 


OBTHOPEDIC   SUBGEBY. 


The  Lower  Region. — Tlie  prognosis  is  good  in  disease  of  the 
lower  region,  and  one  may,  as  a  rule,  predict  recovery  without 
noticeable  deformity ;  at  most,  but  a  slight  shortening  and 
broadening  of  the  trunk  and  a  peculiar  erectness  of  attitude. 

The  brace  is  the  better  support  when  the  disease  is  near  the 
sacrum,  while  the  jacket  is  often  more  comfortable  and  more 
effective  than  the  brace  when  the  middle  or  upper  lumbar  region 

Fig.  75. 


The  final  result  of  extreme  psoas  contraction.     The  direct  bone  deformity  being 
comparatively  slight. 


is  diseased,  particularly  when  lateral  deviation  of  the  spine  is 
present. 

The  most  troublesome  complications  of  this  region  are  psoas 
contraction  and  the  abscess  with  which  it  is  often  combined. 

As  has  been  stated,  psoas  contraction  changes  the  attitude 
of  overerectness,  favorable  to  repair,  to  a  forward  stoop  that 


TUBERCULOUS    DISEASE    OF    THE    SPINE. 


107 


increases  the  pressure  and  friction  at  the  seat  of  disease.  If 
this  attitude  persists  and  if  it  becomes  fixed  bj  permanent 
changes,  such  as  are  likely  to  follow  the  burrowing  of  a  pelvic 
abscess  most  disastrous  deformity  may  result ;  the  body  and  the 
thighs  are  approximated   and  the  erect  attitude  is  made  im- 


FiG.  76. 


Final  result  of  lumbar  disease ;  spontaneous  absorption  of  abscess,  and  but 
slight  deformity.      (See  Pig.   13.) 

possible.  In  neglected  cases  of  this  character,  tenotomy  and 
forcible  correction  or  even  subtrochanteric  osteotomy  may  be 
necessary  to  overcome  the  secondary  deformity.  In  ordinary 
cases  of  psoas  contraction,  and  when  one  limb  only  is  flexed,  the 
patient  may  be  allowed  to  go  about  with  crutches  using  a  high 
shoe  on  the  unaffected  side,  so  that  the  flexed  limb  need  not 
affect  the  attitude.     If,  however,  the  contraction  persists,  it  is 


108  ORTHOPEDIC    SUEGEBT. 

well  to  place  the  patient  on  a  frame,  and  to  reduce  the  flexion 
by  traction  in  the  line  of  deformity,  or  it  may  be  directly  re- 
duced under  ansesthesia  and  restrained  by  a  spica  jacket  as  will 
be  described  in  the  treatment  of  disease  of  the  hip-joint.  Per- 
sistent psoas  contraction  is  almost  always  a  symptom  of  abscess 
about  the  origin  or  in  the  substance  of  the  muscle,  and  when  it 
is  accompanied  by  pain  it  is  always  an  evidence  of  progressive 
disease. 

Abscess  may  be  expected  as  a  complication  in  at  least  50  per 
cent,  of  the  cases  of  disease  of  this  region,  but  it  is  by  no  means 
always  accompanied  by  psoas  contraction,  any  more  than  psoas 
contraction  is  always  symptomatic  of  abscess.  Abscess  unac- 
comj)anied  by  contraction  usually  has  its  origin  above  the  lum- 
bar region,  and  does  not  involve,  therefore,  the  substance  of  the 
psoas  muscle.     The  treatment  of  abscess  is  considered  elsewhere. 

Disease  of  the  Middle  and  Upper  Dorsal  Region. — This  is,  from 
the  standpoint  of  prevention  of  deformity,  the  most  difiicult 
region  of  the  spine  to  treat,  although  the  symptoms  of  the  disease 
may  be  easily  relieved. 

Deformity  is  present  in  nearly  all  cases  when  treatment  is 
sought,  and  it  is  difficult  to  check  its  progress  for  the  reasons 
that  have  been  stated  already. 

The  final  result  in  the  majority  of  cases  is  what  appears  to  be 
exaggerated  round  shoulders ;  the  neck  is  shortened  and  projects 
forward,  the  chest  is  flat,  and  the  shoulders  are  high. 

In  all  cases  of  disease  above  the  ninth  vertebra,  the  shoulders 
should  be  restrained  to  secure  greater  fixation  of  the  spine ;  and 
in  all  cases  above  the  seventh  or  eighth  vertebra  a  head  or  chin 
support  is  indicated  in  addition.  It  is  in  the  treatment  of 
disease  of  this  region  that  the  Calot  jacket  is  particularly  in- 
dicated. 

In  this  region  of  the  spine  paralysis  is  a  frequent  complica- 
tion. When  it  appears  after  treatment  is  begun,  it  is  usually 
a  result  of  inefficient  fixation  of  the  spine  or  of  want  of  caution 
in  regulating  the  strain  to  which  the  diseased  part  is  subjected. 
Its  symptoms  and  its  treatment  will  be  considered  later. 

Disease  of  the  Upper  Dorsal  and  Middle  Cervical  Region.— This 
is  the  most  favorable  region  of  the  spine  for  treatment.  The 
disease  is  usually  not  extensive  because  of  the  small  size  and 
compact  structure  of  the  vertebrfe;  and  the  mobility  of  the 
cervical  region  is  so  great  that  it  readily  compensates  for  the 
local  rigidity.     Under  efficient  treatment  one  may  predict  re- 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  109 

coverv  without  noticeable  deformity,  and  in  the  less  successful 
cases  it  is  not,  as  a  rule,  offensive.  The  shoulders  appear  high, 
the  neck  is  short,  the  head  inclines  forward,  while  the  back  is 
abnormally  flat  in  compensation  for  the  change  in  contour  of 
the  jDart  above. 

When  the  case  of  cervical  disease  is  first  brought  for  treat- 
ment a  wrynecJi  deformity,  often  made  more  persistent  by  the 
infiltration  of  an  abscess  or  by  enlarged  cervical  glands,  is 
almost  always  present.  As  a  means  of  correcting  this  distortion, 
the  jury-mast  and  traction  halter  is  a  very  efficient  and  com- 
fortable support.  Under  the  constant  tension  the  deformity 
may  be  corrected  with  ease,  but  as  a  permanent  treatment  more 
exact  fixation  by  means  of  the  metallic  support  or  the  Calot 
jacket  is  preferable. 

Disease  of  the  Occipitoaxoid  Region. — Under  the  efficient  treat- 
ment the  prognosis  is  good,  and  recovery  without  deformity 
should  be  the  rule.  The  course  of  the  disease,  although  it  is 
often  accompanied  by  acute  symptoms,  is  usually  short,  as  com- 
pared with  that  of  other  regions  of  the  spine.  It  may  be 
assumed  that,  in  many  cases,  it  is  a  primary  arthritis,  or,  at 
least,  that  the  primary  focus  in  the  atlas  or  axis  is  very  small. 
The  disease  at  this  j)oint  is,  however,  in  close  proximity  to  the 
vital  centres,  and  sudden  death  from  displacement  of  the 
weakened  parts  is  not  uncommon.  Abscess  is  frequent,  and  it 
is  often  a  troublesome  and  dangerous  complication. 

If  wryneck  deformity  is  present  it  should  be  reduced  by 
traction  either  in  bed  or  by  means  of  the  jury-mast.  The  head 
should  then  be  fixed  in  an  attitude  of  slight  extension  by  an 
efficient  head  brace  or  by  the  Calot  or  similar  support.  Ke- 
cumbency  is  indicated  during  acute  phases  of  the  disease. 

Abscess  Complicating  Pott's  Disease. — It  may  be  assumed 
that  a  limited  collection  of  tuberculous  fluid  is  present  at  some 
time  during  the  course  of  Pott's  disease  in  the  great  majority 
of  cases,  but  unless  it  appears  as  a  palpable  tumor  above  or 
below  the  thorax  or  upon  the  surface  of  the  body  its  presence  is 
not  often  detected. 

Townsend,^  in  380  cases  of  Pott's  disease  examined  with 
reference  to  the  occurrence  of  abscess  as  a  complication,  found 
that  it  was  present  or  had  been  detected  in  75  (19.Y  per  cent.)  ; 
in  8  per  cent,  of  the  cases  of  cervical  disease ;  in  20  per  cent,  of 
the  dorsal,  and  in  72  per  cent,  of  those  in  which  the  lumbar 
region  was  involved. 

'  Transactions  American  Orthopedic  Association,  vol.  iv.,  p.  166. 


110  OBTEOPEDIC    SUEGEBY. 

Dollinger,^  in  TOO  cases  under  treatment  from  1883  to  1895, 
found  abscess  in  154  (22  per  cent.)  ;  in  13  of  63  cases  in  tlie 
cervical  region  (22.6  per  cent.)  ;  in  47  of  403  cases  in  tlie 
thoracic  region  (11.6  per  cent.),  and  in  94  of  234  cases  of  lum- 
bar disease  (40.17  per  cent.). 

Ketch,^  in  75  cured  cases  of  Pott's  disease  treated  at  tbe  ISTew 
York  Orthopedic  Dispensary,  selected  for  the  purpose  of  con- 
trasting the  behavior  of  the  disease  in  the  different  regions  of 
the  spine,  found  that  abscess  had  appeared  in  19  (25.3  per 
cent.).  In  the  upper  region  abscess  was  detected  in  but  1  of 
the  25  cases  (4  per  cent.)  ;  in  the  middle  region  in  8  of  the  25 
cases  (32  per  cent.),  and  in  the  lov^er  in  10  (40  per  cent.). 

In  354  autopsies  by  Mohr,  IsTebel,  Bouvier,  and  Lannelongue 
abscess  was  found  in  281,  or  nearly  80  per  cent. 

Although  cases  of  Pott's  disease  that  come  to  autopsy  may  be 
supposed  to  represent  a  severe  type  of  disease,  yet  it  is  evident, 
by  contrasting  the  statistics,  that  a  large  proportion  of  the  ab- 
scesses escape  detection  in  the  living.  One  may  conclude,  then, 
that  abscess  may  be  expected  as  a  more  or  less  serious  complica- 
tion in  25  per  cent,  of  all  cases  of  Pott's  disease,  and  in  at  least 
half  of  those  in  which  the  lower  region  of  the  spine  is  affected. 
The  greater  frequency  here  is  explained  by  the  large  size  and 
less  resistant  structure  of  the  vertebral  bodies  as  compared  with 
those  of  the  upper  regions. 

The  tuberculous  abscess  is  separated  from  the  neighboring 
parts  by  a  limiting  wall  varying  in  thickness  according  to  its 
age,  the  outer  layers  of  which  are  of  fibrous  and  cellular  tissue, 
the  inner  of  granulation  tissue  covered  with  yellowish-gray  or 
pinkish-gray  necrotic  membrane,  which  is  easily  separated  from 
the  underlying  parts.  The  fluid  of  the  abscess  is  usually  of  a 
whitish  or  whey-like  color,  composed  of  serum,  leukocytes,  and 
emulsified  caseous  material  and  fibrin.  Floating  in  it  are 
masses  of  cheesy  necrotic  tissue  and  sometimes  minute  frag- 
ments of  bone,  which  settle  to  the  bottom  of  the  glass.  Certain 
of  the  smaller  quiescent  abscesses  contain  only  this  whitish  semi- 
solid material.  The  fluid  of  abscesses  in  process  of  resolution 
is  often  clear,  like  serum;  but  if  secondary  infection  has  taken 
place  the  pus  is  of  a  greenish-yellow  color,  and  is  of  uniform 
consistency.  At  any  stage  of  its  progress  the  abscess  may  be- 
come stationary  and  its  contents  may  be  absorbed ;  in  fact,  such 

^  Loc.  cit. 

-  Transactions  American  Orthopedic  Association,  vol.  iv.,  p.  200. 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  Ill 

an  outcome  is  not  unusual.  The  fluid  of  the  abscess  is  usually 
sterile,  and  secondary  infection,  before  a  communication  with 
the  exterior  of  the  body  is  established,  is  uncommon. 

Abscess  is  a  symptom  of  disease,  and  it  is  in  some  degree  an 
evidence  of  its  character.  If  it  appears  early  and  increases  in 
size  rapidly  it  usually  indicates  a  destructive  and  rapidly  ad- 
vancing process.  On  the  other  hand,  the  slowly  enlarging  or 
quiescent  abscess  has  but  little  significance.  The  abscess  may 
cause  no  symptoms  whatever,  or  it  may  be  a  source  of  incon- 
venience simply  because  of  its  size  or  situation.  In  many  in- 
stances, however,  a  period  of  malaise  or  discomfort  or  pain  is 
followed  and  explained  by  the  appearance  of  an  abscess,  but 
whether  the  symptoms  are  caused  by  the  tension  of  the  abscess 
or  by  a  more  acute  phase  of  the  disease  itself  is  not  always  clear. 

Large  abscesses  that  are  increasing  in  size  and  approaching 
the  surface  are  usually  accompanied  by  pain  and  by  elevation 
of  temperature.  This  may  indicate  a  slight  degree  of  secondary 
infection,  but  the  ordinary  deep  abscess  appears  to  have  no 
other  effect  than  to  add,  doubtless,  to  the  susceptibility  of  the 
patient. 

The  Course  and  Peculiarities  of  Abscess  in  the  Different  Regions 
of  the  Spine.. — The  tuberculous  abscess  may  remain  as  a  small 
collection  of  fluid  in  the  neighborhood  of  the  diseased  area.  As 
a  rule,  however,  it  slowly  increases  in  size,  and  under  the  in- 
fluences of  the  force  of  gravity  and  the  tension  of  its  contents  it 
finds  its  way  down  the  spine  or  toward  the  exterior  of  the  body, 
following  the  path  of  least  resistance.  The  abscesses  that  have 
passed  below  the  diaphragm  or  that  have  originated  below  this 
]Doint  may  follow  various  paths.  Some  enter  the  sheath  of  the 
psoas  muscle,  and  finally  make  their  appearance  on  the  inner 
aspect  of  the  thigh,  psoas  abscess.  Others  perforate  the  sheath 
of  the  quadratus  lumborum  muscle  and  form  a  lumbar  abscess, 
projecting  between  the  twelfth  rib  and  the  crest  of  the  ilium  at 
the  triangle  of  Petit.  Those  abscesses  that  escape  from  the 
fascia  of  the  psoas  muscle  or  that  pass  dovniward  on  the  surface 
of  the  iliac  fascia,  the  so-called  iliac  abscesses,  may  appear  as  a 
tumor  over  the  outer  extremity  of  Poup art's  ligament  at  the 
junction  of  the  transversalis  and  iliac  fascise,  or  the  fluid  may 
follow  the  course  of  the  iliac  artery  to  the  thigh,  or,  escaping 
from  the  greater  sacrosciatic  foramen,  form  a  gluteal  abscess. 
The  iliac  or  psoas  abscess  is  most  often  confined  to  one  side,  but 
it  may  be  bilateral,  the  two  sacs  communicating  with  one 
another  by  a  larger  or  smaller  channel. 


112 


OFTHOPEDIC    SUEGEEY. 


In  the  thoracic  region  the  abscess  may  remain  indefinitely  in 
the  posterior  mediastinum,  where,  if  large,  its  presence  may  be 
demonstrated  by  an  area  of  dnlness  extending  toward  the  lateral 
region  of  the  thorax,  or  it  may  perforate  the  intercostal  muscles 
and  appear  on  the  posterior  or  lateral  aspect  of  the  chest,  or  it 
may  pass  downward  through  the  aortic  opening  in  the  dia- 
phragm and  become  an  iliac  abscess. 

Abscess  caused  by  disease  of  the  occipitoaxoid  region  may 
force  its  way  forward  between  the  recti  muscles  and  appear  be- 

FiG.  77. 


Bilateral    lumbar   abscess. 


hind  the  pharynx  as  the  retropharyngeal  abscess,  or  the  fluid 
may  take  the  opposite  direction  and  distend  the  suboccipital 
triangle  and  then  pass  forward  to  the  region  of  the  mastoid 
process.  In  other  instances  the  abscess  may  dissect  its  way 
about  the  base  of  the  skull  or  pass  upward  through  the  foramen 
magnum  or  downward  into  the  spinal  canal. 

Abscesses  from  the  middle  cervical  region  usually  pass  out- 
ward between  the  scaleni  and  loneus  colli  muscles  to  the  interval 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  113 

between  the  trapezius  and  sternomastoid,  perforating  the  skin 
about  the  middle  of  the  lateral  aspect  of  the  neck  near  the 
anterior  border  of  the  latter  muscle. 

These  are  the  paths  usually  followed  bj  the  tuberculous  fluid, 
but  occasionally  it  may  enter  the  spinal  canal  or  break  into  the 
pleural  cavity  or  lung  or  intestine  or  by  the  side  of  the  rectum 
or  elsewhere. 

Treatment  of  Abscess. — Abscess  is  by  far  the  most  serious  com- 
plication of  Pott's  disease.  It  may  interfere  with  proper 
mechanical  treatment,  and  it  is  often  a  cause  of  permanent  de- 
formity. It  prolongs  the  course  of  the  disease  by  extending  its 
boundaries,  and,  although  it  is  not  often  an  immediate  cause  of 
death,  yet  many  patients  die  because  of  the  exhaustion  of  long- 
continued  suppuration  and  of  the  amyloid  degeneration  that 
may  finally  result. 

A  large  abscess  is  always  a  source  of  danger  because  of  the 
possibility  of  secondary  infection  of  its  contents  before  it  finds 
an  outlet,  and  because  of  the  probability  of  infection  when  a 
communication  with  the  exterior  has  been  established.  Abscess 
is,  however,  a  symptom  and  result  of  disease,  and  in  properly 
treated  cases  it  is,  as  a  rule,  a  complication  of  comparatively 
slight  consequence.  If  it  is  not  present  when  treatment  is  be- 
gun, one  may  hope  to  prevent  it  by  effective  protection  of  the 
spine ;  and  if  it  is  present,  this  protection  should  be  all  the  more 
rigidly  enforced.  An  abscess  often  exists  for  months  before  its 
presence  is  detected,  and  after  its  discovery  it  may  remain 
quiescent  for  a  long  time,  and  finally  disappear. 

In  a  large  proportion  of  cases  the  abscess  causes  no  symp- 
toms, but  slowly  finds  its  way  to  the  surface  of  the  body.  Mean- 
while it  may  be  assumed  that  the  disease  of  the  spine,  of  which 
the  abscess  is  a  result,  is  in  process  of  cure ;  so  that  when  the 
fluid  finds  an  outlet  the  source  of  supply  will  be  shut  off,  and 
thus  the  jDatient  is  spared  the  danger  and  discomfort  of  discharg- 
ing sinuses,  that  so  often  persist  after  early  operation. 

The  so-called  radical  treatment  of  the  abscess  of  spinal  disease 
is  unsatisfactory,  because  it  is  impossible  to  remove  the  disease 
of  which  the  abscess  is  a  symptom. 

As  the  abscess  is  a  symptom  of  disease,  so,  as  a  rule,  its 
treatment  should  be  symptomatic.  The  retropharyngeal  abscess 
demands  j)rompt  evacuation,  because  it  is  likely  to  obstruct 
breathing  and  swallowing,  because  its  sudden  rupture  may  cause 
death,  and  because  an  abscess  in  such  close  proximity  to  the 


114  OBTHOPEDIC    SUBGEEY. 

vital  centres  is  always  a  source  of  danger.  In  cases  of  emer- 
gency the  abscess  may  be  evacuated  by  an  incision  in  tbe  middle 
line  of  the  pharynx,  but  preferably  the  opening  should  be  from 
the  exterior.  An  incision  is  made  along  the  posterior  aspect  of 
the  sterno-mastoid  muscle  in  its  uj)per  third.  The  abscess 
tumor  is  easily  reached  by  careful  dissection,  and  drainage  is 
established  which  has  evident  advantages  over  that  into  the 
throat. 

Abscesses  from  the  middle  cervical  region  usually  point  in 
the  lateral  region  of  the  neck  and  cause  but  little  inconvenience. 
Abscesses  in  the  upper  thoracic  region  may,  in  rare  instances, 
cause  dangerous  pressure  on  the  trachea  or  bronchi,  as  shown 
by  spasmodic  attacks  of  inspiratory  dyspnoea,  "  asthmatic 
attacks."  In  some  instances  an  area  of  dulness  near  the  seat  of 
disease  demonstrates  the  position  of  the  abscess,  but  if  it  lies  in 
the  median  line  it  cannot  be  detected  either  by  auscultation  or 
percussion.  If  the  inspiratory  dyspnoea  is  well-marked  the 
symptom  may  be  fairly  attributed  to  this  cause,  and  if  the 
spasmodic  attacks  are  frequent  and  severe  the  operation  of 
costotransversectomy  is  indicated.  An  incision  is  made,  prefer- 
ably on  the  right  side,  to  expose  the  articulation  between  the 
transverse  process  and  the  rib,  and  one  or  two  of  these  joints  is 
resected;  the  finger  is  then  inserted  and  passed  along  the  sur- 
face of  the  adjacent  vertebral  body  until  the  abscess  sac  is 
reached.  This  is  usually  directly  in  front  of  the  spine  at  or 
about  the  fifth  dorsal  vertebra.  After  incision  a  drainage  tube 
should  be  inserted  (Fig.  9).  The  same  procedure  should  be 
considered  whenever  abscess  and  paraplegia  are  combined  as  it 
is  quite  possible  that  the  paralysis  is  dependent  on  the  pressure 
of  the  abscess. 

In  the  lower  region  of  the  spine  intervention  may  be  indi- 
cated because  there  is  evidence  of  secondary  infection.  In  this 
event  if  the  abscess  distends  the  lumbar  region  or  forms  a  sac 
on  either  side  of  the  spine,  an  opening  in  the  loin  on  one  or 
both  sides  of  the  spine  is  necessary.  This  is  made  as  in  opera- 
tions on  the  kidney,  by  an  incision  on  the  outer  side  of  the 
erector  spinse  muscle  between  the  last  rib  and  the  crest  of  the 
ilium.  In  certain  cases  it  is  possible  to  expose  the  spine  and  to 
remove  fragments  of  necrosed  bone  along  with  the  contents  of 
the  abscess.  As  a  rule,  the  complete  removal  of  the  lining  mem- 
brane of  the  abscess  is  not  practicable,  and  one  must  be  content 
to  evacuate  the  solid  and  semisolid  contents  by  flushing  with 


TUBERCULOUS    DISEASE    OF    TEE    SPINE.  115 

hot  water,  together  with  as  much  of  the  abscess  membrane  as 
may  be  removed  by  swabbing  with  gauze.  The  most  important 
point  in  the  operation  is  to  provide  efficient  and  complete  drain- 
age of  the  cavity.  Two  or  more  counteropenings  are  usually 
necessary  when  the  lumbar  incision  has  been  made',  one  just  in 
front  of  the  anterior  superior  spine  and  another  in  the  thigh, 
if  the  abscess  is  of  the  psoas  variety.  Long  drainage  tubes  are 
inserted,  and  should  remain  until  a  proper  channel  for  the 
escape  of  pus  has  been  established. 

If  the  abscess  is  of  one  side  only,  not  extending  into  the 
thigh,  and  if  evacuation  seems  advisable  because  of  its  size  or 
tension,  it  may  be  opened  by  an  anterior  incision  below  Pou- 
part's  ligament  just  to  the  inner  side  of  the  sartorius  muscle. 
After  expression  of  its  contents  a  drainage  tube  may  be  inserted 
long  enough  to  reach  to  the  seat  of  disease  if  it  be  of  the  lumbar 
region. 

The  dressing  should  be  of  dry  sterile  gauze,  and  great  atten- 
tion should  be  paid  to  absolute  cleanliness  and  to  effective  drain- 
age. As  soon  as  it  is  possible,  if  the  discharge  has  become  slight 
and  if  the  spine  can  be  properly  supported,  the  patient  is 
allowed  to  walk  about  and  to  go  into  the  open  air.  In  ordinary 
cases  a  slight  discharge  persists  for  several  months  or  longer, 
depending  on  the  condition  of  the  disease. 

In  the  symptomatic  treatment  of  abscess,  aspiration  is  some- 
times of  service,  for  by  this  means  it  may  be  prevented  from 
increasing  in  size ;  and  if  the  disease  is  quiescent,  the  cure  of 
the  abscess  may  follow  the  removal  of  its  contents  which  allows 
the  collapse  of  its  walls.  When  aspiration  is  employed  it 
should  be  repeated  systematically  as  often  as  the  abscess  cavity 
refills.  After  each  evacuation  pressure  should  be  applied  to 
favor  the  adhesion  of  the  apposed  walls. 

If  the  contents  are  of  such  a  nature  that  aspiration  is  ineffec- 
tive an  incision  may  be  made,  through  which  the  semisolid  sub- 
stance may  be  removed.  The  opening  is  then  closed  by  several 
layers  of  sutures,  and  pressure  is  applied  with  the  aim  of  ob- 
taining primary  union.  This  operation  may  be  repeated  sev- 
eral times  if  necessary.  Often  a  sinus  eventually  forms  at  one 
or  other  of  the  openings. 

The  injection  of  antituherculous  remedies  although  they  may 
have  no  direct  influence  on  the  disease  may  diminish  the  infec- 
tive quality  of  the  fluid  and  solid  contents  of  the  abscess  and 
stimulate  the  reparative  processes  that  check  its  progress.     An 


116  OETROPEDIC    SUEGERY. 

emulsion  of  iodoform  in  sterilized  oil  or  glycerin  (10  to  20 
per  cent.)  is  often  used.  This,  in  doses  of  from  4  to  30 
grams,  is  injected  at  intervals  of  from  two  to  four  weeks, 
after  evacuation  of  the  contents ;  the  amount  and  the  frequency 
of  the  injection  depending  upon  the  age  of  the  patient  and  upon 
the  effect  of  the  treatment.  If  used  with  caution  as  to  asepsis, 
and  to  the  toleration  of  the  patient  for  iodoform,  no  harm  will 
follow,  even  if  the  treatment  proves  to  be  of  little  j)ractical 
value. 

Calot  favors  frequent  aspirations  usually  at  intervals  of  a 
week  or  more  and  injection  of  a  fluid  composed  of : 

Sterilized   oil 70  grammes. 

Ether 30  grammes. 

Creasote   6  grammes. 

Iodoform    10  grammes. 

2-12  grammes  are  injected  according  to  the  age  of  the  child. 

The  abscess  is  aspirated  as  often  as  pus  accumulates  and  the 
average  number  of  injections  is  10—12.  When  the  fluid  with- 
drav^Tti  becomes  serous  in  character  the  injections  are  dis- 
continued. 

As  the  abscess  approaches  the  surface  the  skin  becomes  red 
and  thin,  and  there  is  usually  some  local  sensitiveness  and  pain. 
Whenever  spontaneous  evacuation  of  the  abscess  is  probable  the 
mother  should  be  instructed  as  to  the  necessity  of  absolute  clean- 
liness, and  the  proper  dressings  should  be  provided.  In  such  an 
event  the  patient  should  remain  in  bed  for  several  days,  or  until 
the  discharge  has  become  small  in  amount. 

In  the  symptomatic  treatment  of  the  abscesses  of  Pott's  disease 
one  may  conclude,  then,  that  operation  will  be  indicated  in  the 
'treatment  of  the  retropharyngeal  abscess  and  in  the  rare  in- 
stances when  dangerous  pressure  is  exerted  by  an  abscess  in  the 
posterior  mediastinum.  It  is  indicated,  of  course,  when  there 
is  evidence  of  mixed  infection  or  when  the  rapidly  enlarging 
abscess  causes  discomfort  or  interferes  with  effective  support. 
It  is  usually  indicated  when  the  abscess  is  of  large  size  if  proper 
care  can  be  provided.  The  operative  treatment  is  practically 
free  from  danger  if  cleanliness  and  efficient  drainage  can  be 
assured.  Aspiration  is  free  from  danger;  it  is  often  of  service 
in  preventing  the  enlargement  of  the  abscess,  and  it  may  hasten 
its  absorption.  An  incision  which  allows  for  the  evacuation  of 
the  solid  material,  followed  by  immediate  closure  of  the  wound, 
is  in  many  instances  the  operation  of  selection. 


TUBEECULOUS    DISEASE    OF    THE    SPINE.  117 

If  the  abscess  cavit}^  after  the  removal  of  its  contents  is  not 
large,  it  may  be  filled  with  Beck's  mixture  of  bismuth  and 
vaseline  1-3,  injected  at  a  temjjerature  of  110°.  This  treat- 
ment is  described  in  Chapter  V. 

Paralysis  ("  Pott's  Paraplegia  ")  Complicating  Pott's  Dis- 
ease.-— The  tuberculous  process  in  the  vertebral  bodies  may  ex- 
tend backward,  and  breaking  through  the  posterior  ligament  it 
may  enter  the  epidural  space  and  press  upon  the  spinal  cord ; 
then  follows  paresis  or  paralysis  of  the  parts  below  the  con- 
striction. 

The  calibre  of  the  spinal  canal  is  not  usually  lessened  by  the 
characteristic  angular  distortion  of  the  spine,  although  the 
weight  and  forward  inclination  of  the  trunk  may  force  the 
softened  tissues  backward  against  the  cord  and  thus  increase 
the  direct  pressure.  In  fact,  paralysis  is  much  more  often 
associated  with  a  slight  or  moderate  kyphosis  than  with  ex- 
treme deformity. 

In  rare  instances  the  pressure  may  be  due  to  a  fragment  of 
necrosed  bone  or  to  solidification  of  the  tissues  in  and  about  the 
canal  during  the  process  of  repair.  It  may  be  caused,  in  part, 
at  least,  by  the  pressure  of  a  neighboring  abscess,  but  it  is 
usually  the  result  of  the  slow  advance  of  the  tuberculous  dis- 
ease. When  this  has  forced  an  entrance  into  the  spinal  canal 
it  sets  up  a  resistant  inflammatory  thickening  of  the  coverings 
of  the  cord — first  a  peripachymeningitis  and  then  a  pachymen- 
ingitis. In  addition  to  the  direct  pressure,  there  may  be  an 
interference  with  blood  supply  and  the  lymphatic  circulation, 
with  resulting  local  oedema  of  the  cord.  An  increase  in  the 
interstitial  connective  tissue  of  its  substance  and  a  correspond- 
ing atrophy  of  the  nervous  elements  may  follow,  and  as  a 
sequence  an  ascending  and  descending  degeneration  that,  in 
prolonged  cases,  may  terminate  in  partial  or  complete  sclerosis. 
The  dura  mater  is  a  resistant  structure,  and  direct  destruction 
of  the  cord  by  the  tuberculous  disease  is  rare.  In  fact,  as  a 
rule,  but  little  permanent  damage  results,  even  from  long-con- 
tinued pressure  and  paralysis,  for  the  'cord  seems  in  these  cases 
to  possess  the  power  of  repair  and  regeneration  to  a  remarkable 
degree. 

Frequency.- — In  1670  cases  of  Pott's  disease  recorded  at  the 
ISTew  York  Orthopedic  Dispensary,  paralysis  occurred  in  218,^ 

'  Myers,  Transactions  American  Orthopedic  Association,  1891,  vol.  iii., 
p.  209. 


118  OETHOPEDIC    SUEGEEY. 

and  in  445  cases  in  the  private  practice  of  Dr.  C.  F.  Taylor/ 
59  cases  of  paralysis  were  observed.  Thus,  in  a  total  of  2015 
cases  of  Pott's  disease  there  were  279  cases  of  paralysis,  or  13.7 
per  cent. 

This  proportion  is  much  larger  than  the  normal,  however, 
for  many  of  the  patients  were  taken  to  the  special  hospital  be- 
cause of  the  pai'alysis,  as  in  40  of  Taylor's  and  in  133  of  the 
dispensary  cases.  If  these  be  excluded,  the  percentage  of 
paralysis  occurring  in  those  actually  under  treatment  is  re- 
duced to  5.6  per  cent.  This  percentage  corresponds  very  closely 
to  that  of  DoUinger,^  viz.,  41  cases  of  paralysis  in  700  cases  of 
Pott's  disease  under  treatment  (5.8  per  cent.),  and  it  may  be 
accepted  as  representing  the  average  liability  to  paralysis  among 
those  who  have  received  treatment  for  Pott's  disease,  the  per- 
centage being  much  higher  in  neglected  cases. 

The  Liability  to  Paralysis  in  Disease  of  the  Different  Regions  of 
the  Spine, — The  liability  to  paralysis  is  very  much  greater  in 
disease  of  certain  regions  of  the  spine  than  in  others. 

Thus,  105  of  the  209  cases  in  Myers'  list,  in  which  the  situa- 
tion of  the  disease  was  recorded,  complicated  disease  of  the 
dorsal  region  above  the  eighth  vertebra.  Of  the  remainder,  in 
16  the  disease  was  of  the  cervical  region ;  in  12  of  the  cervico- 
dorsal,  and  in  59  of  the  lower  dorsal  and  dorsolumbar  regions. 

Thirty-seven  of  Taylor's  59  cases  were  caused  by  disease  of 
-the  dorsal  region;  8  occurred  in  the  cervical  and  cervicodorsal 
and  11-  in  the  dorsolumbar  and  lumbar  regions. 

Twenty-six  of  the  total  of  41  cases  recorded  by  DoUinger  were 
caused  by  disease  of  the  third  to  the  seventh  dorsal  vertebrae, 
inclusive,  or  about  23  per  cent,  of  the  cases  in  which  this  region 
was  involved. 

Of  132  cases  of  paraplegia  reported  by  Gibney^  not  one  com- 
plicated lumbar  disease ;  nearly  all  were  caused  by  compression 
in  the  middle  or  upper  thoracic  region. 

These  statistics  show  that  the  upper  and  middle  dorsal  sec- 
tion is  the  point  of  greatest  liability  to  paralysis — a  fact  that  is 
explained  possibly  by  the  smaller  size  of  the  canal  at  this  point, 
and  by  the  difficulty  in  assuring  complete  fixation  at  the  seat  of 
disease.  It  may  be  estimated  that  in  15  per  cent,  of  the  cases 
of  Pott's  disease  of  this  region  paralysis  will  appear  before  cure 
is  established. 

'  Taylor  and  Lovett,  New  York  Medical  Eeeord,  June  19,  1896. 

-  Loc.  cit. 

=  Journal  of  Nervous  and  Mental  Disease,  January,  5,  1897. 


TUBEECULOUS    DISEASE    OF    THE    SPINE.  119 

Time  of  Onset. — In  exceptional  cases  the  paralysis  may  pre- 
cede deformity,  and  it  may  be  the  first  symptom  that  attracts 
attention  to  the  disease.  In  14  of  74  cases  reported  by  Gibney 
the  paralysis  was  present  when  the  bone  disease  was  recognized, 
but  it  is  probable  that  the  primary  disease  had  existed  for 
several  months  before  the  appearance  of  the  paralysis.  Usually 
it  is  a  comparatively  late  symptom,  appearing  after  the  stage  of 
deformity  and  more  often  six  to  twelve  months  after  the  recog- 
nition of  the  disease,  but  its  appearance  may  be  deferred  until 
long  after  apparent  cure. 

Duration. — In  exceptional  cases  the  paralysis  appears  to  be 
caused  simply  by  disturbance  of  the  circulation  of  the  cord,  due 
possibly  to  the  pressure  of  the  superincumbent  weight  upon  the 
softened  and  diseased  tissues,  as  it  disappears  almost  imme- 
diately when  the  spine  is  straightened  and  supported.  Usually 
the  paralysis  persists  for  several  months,  not  infrequently  it 
lasts  a  year,  and  partial  or  even  complete  recovery  is  possible 
after  a  much  longer  time.  Recovery  from  the  paralysis  de- 
pends upon  the  course  of  the  disease  of  which  it  is  a  symptom, 
upon  the  absorption  and  organization  of  the  tuberculous  granu- 
lations that  press  upon  the  cord,  and  upon  the  regenerative 
changes  in  its  structure,  if  it  has  been  implicated  in  the  disease. 

Symptoms, — The  most  marked  effect  of  the  pressure  on  the 
cord  is  the  interference  with  its  conductivity.  The  reflex 
centres  situated  below  the  point  of  constriction,  relieved  from 
the  inhibition  of  the  brain,  become  overactive,. while  voluntary 
motion  of  the  parts  below  the  constriction  is  difficult  or  impos- 
sible. The  pressure  of  the  diseased  products  is  more  directly 
upon  the  anterolateral  columns,  so  that  motion  is  much  more 
often  primarily  affected  than  is  sensation. 

The  early  symptoms  of  Pott's  paraplegia,  are  weakness, 
awkwardness,  and  a  stumbling,  shambling  gait.  The  symp- 
toms usually  increase  rapidly  until  paralysis  of  motion  is  com- 
plete. At  this  stage  the  patella  tendon  reflex  is  increased,  and 
ankle-clonus  is  often  present.  As  a  rule,  both  limbs  are  affected 
in  equal  degree,  but  occasionally  paralysis  of  one  may  be  more 
complete  or  may  precede  that  of  the  other,  and  in  the  stage  of 
recovery  power  may  return  more  rapidly  on  one  side  than  on 
the  other.  The  limbs  in  the  early  stage  of  the  paralysis  may 
appear  limp  and  powerless,  but  when  the  patient  is  moved  or 
when  the  reflexes  are  stimulated  the  peculiar  spastic  rigidity  or 
stiffness  appears. 


120  OBTEOPEDIC    SUEGEBY. 

As  a  rule,  the  stiffness  increases  with  the  duration  of  the  dis- 
ease, and  spastic  contractions  are  often  present ;  thus,  the  thighs 
may  be  aj^proximated,  the  knees  flexed,  and  the  feet  extended. 
Persistent  contractions  indicate,  as  a  rule,  permanent  damage 
to  the  cord,  and  in  such  cases  complete  recovery  is  unusual. 

Fig.  78. 


Pott's    paraplegia    before    the    stage    of    deformity.     The    apparatus    used    in    the 
treatment  of  this   case  is  shown  in  Fig.  47. 

Sensation  is  not  affected  ordinarily,  but  in  the  more  severe  or 
prolonged  cases  it  may  be  impaired  or  lost.  Sensation  was  re- 
tained throughout  in  24  of  the  40  cases  reported  by  Shaffer. 

In  the  cases  of  partial  j^aralysis  control  of  the  bladder  may  be 
retained,  but  usually  there  is  incontinence.  As  the  bladder  fills 
the  reflex  centre    is  excited,  and  it  empties  itself. 

The  control  of  the  sphincter  ani  is  less  often  or  less  noticeably 
affected. 

As  the  paralysis  is  the  result  in  many  instances  of  active  or  of 
advancing  disease  its  onset  may  be  preceded  by  discomfort  or 
pain.  Thus,  noticeable  discomfort  attended  by  an  exaggeration 
of  the  patella  tendon  reflex  may  be  considered  as  an  indication 
for  enforced  rest  of  the  individual,  although  increased  activity 
of  the  reflexes  is  not  uncommon  during  the  progressive  stage  of 
the  disease  without  apparent  involvement  of  the  spinal  cord. 
When  paralysis  occurs  in  patients  who  are  under  treatment  for 
Pott's  disease  the  onset  is  not  attended,  as  a  rule,  by  noticeable 
or  unusual  pain ;  nor  is  pain  usually  complained  of  after  the 
paralysis  has  developed. 

The  extent  of  the  paralysis  depends  upon  the  situation  of  the 
disease.  In  exceptional  cases,  in  which  the  cervical  cord  is  im- 
plicated, both  the  arms  and  legs  may  be  paralyzed ;  or  again  there 


TUBEECULOUS    DISEASE    OF    THE    SPINE.  121 

may  be  flaccid  paralysis  of  the  arms  with  spastic  paralysis  of 
the  lower  extremities.  This  occurred  in  seven  of  the  cases  re- 
ported by  Myers.  As  a  rule,  however,  the  paralysis  is  a  com- 
plication of  disease  of  the  dorsal  region  above  the  reflex  centres 
in  the  lumbar  enlargement  of  the  cord  but  below  the  nerve 
supply  of  the  upper  extremities.  If  the  disease  is  at  a  lower 
point,  for  example,  in  the  dorsolumbar  section  so  that  these 
reflex  centres  themselves  are  directly  implicated,  reflex  activity 
is  not  increased,  and  intermittent  incontinence  is  replaced  by 
constant  dribbling  of  urine.  If  the  cauda  equina  alone  is  im- 
plicated in  disease  of  the  lumbosacral  region  the  symptoms  are 
those  of  neuritis,  pain,  numbness,  and  weakness  in  the  area 
supplied  by  the  affected  nerves.  Such  weakness  with  accom- 
panying muscular  atrophy  may  be  present  in  the  upper  ex- 
tremities when  the  disease  is  in  the  neighborhood  of  the  origin 
of  the  brachial  plexus,  while  in  the  lower  limbs  the  character- 
istic spastic  condition  is  evident. 

In  characteristic  cases  the  nutrition  of  the  limbs  is  not,  as  a 
rule,  greatly  affected,  nor  do  the  contractions  become  perma- 
nent ;  but  when  the  paralysis  is  prolonged,  and  when  sensation 
is  lost,  the  muscles  waste,  the  circulation  is  impaired,  and  fixed 
distortions  usually  appear.  Even  in  the  more  prolonged  and 
severe  forms  of  paralysis,  occurring  in  childhood,  bed-sores  are 
rarely  seen. 

Prognosis. — In  properly  treated  cases  the  prognosis  is  very 
favorable,  as  is  illustrated  by  the  final  results  of  47  of  the  59 
cases  of  paraplegia  in  Taylor's  practice.  Of  these  39  recovered 
completely,  5  died  of  intercurrent  disease  while  apparently 
recovering,  and  in  3  the  recovery  was  partial. 

Of  the  hospital  cases  recorded  by  Myers,  3  per  cent,  died  of 
intercurrent  disease.  The  final  results  could  be  ascertained  in 
but  55  per  cent,  of  the  patients.     All  of  these  recovered. 

Of  74  cases  of  paraplegia  treated  by  Gibney,^  45  were  cured, 
12  improved,  8  unimproved,  and  9  died.  Thus,  77  per  cent. 
were  cured  or  improved.  In  a  similar  series  of  40  cases  re- 
ported by  Shaffer,  80  per  cent,  were  cured  and  but  10  per  cent, 
of  the  remainder  were  considered  as  hopeless  cases. 

In  a  total  of  975  cases  "  abandoned  to  medical  treatment," 
collected  from  various  sources  by  Rozoy,^  there  were  429  cures. 
Of  the  remainder  16  were  improved,  130  were  unimproved,  and 

^  Loc.  cit. 

2  Mai.  de  Pott,  Paris,  1901. 


122  OBTHOPEDIC    SUBGEBY. 

there  were  244  deaths.  The  contrast  in  the  results  reported 
would  appear  to  show  the  advantage  of  thorough  mechanical 
treatment. 

Recurrence  of  paralysis  after  recovery  is  not  infrequent ;  in 
18  cases  such  recurrences  from  one  to  four  times  are  recorded 
by  Myers,  and  seven  successive  attacks  of  paralysis  were  ob- 
served in  a  patient  under  treatment  at  the  Hospital  for  Rup- 
tured and  Crippled. 

The  relapses  are  due  apparently  to  the  renewed  activity  of 
the  disease,  and  in  many  instances  this  may  be  explained  by  the 
neglect  of  protective  treatment. 

Treatment. — -The  treatment  of  the  paralysis  is  included  in  the 
treatment  of  the  disease  of  which  it  is  a  symptom,  except  that 
even  greater  care  should  be  exercised  to  assure  fixation  of  the 
spine. 

Rest  in  the  position  of  hyperextension  on  the  stretcher  frame 
is  indicated.  Direct  traction  by  the  weight  and  pulley  may 
be  used  if  the  disease  is  in  the  upper  dorsal  or  cervical  regions. 
For  bedridden  patients  a  convenient  method  of  assuring  exten- 
sion of  the  spine  in  connection  with  head  traction  is  to  suspend 
the  trunk  on  a  sling  of  canvas  drawn  transversely  beneath  the 
seat  of  disease  and  attached  to  bars  on  the  sides  of  the  bed  after 
the  Rauchfuss  method.  The  back  brace  or  the  plaster  jacket 
assures  additional  fixation,  and  such  support  should  be  em- 
ployed in  connection  with  recurrency  whenever  practicable. 
The  Calot  jacket  with  the  greater  fixation  assured  by  the  pres- 
sure over  the  kyphosis  should  be  employed  in  preference  to 
other  supports  of  this  character.  If,  however,  the  brace  has 
been  worn- as  an  ambulatory  support,  its  shape  must  be  modi- 
fied to  accommodate  the  change  in  the  outline  of  the  spine, 
induced  by  recumbency  and  extension. 

Manipulation  or  massage,  of  the  limbs  is  contraindicated  be- 
cause it  stimulates  the  reflexes.  If  persistent  contractions  of 
the  muscles  are  present  the  deformity  may  be  reduced  by  trac- 
tion applied  in  the  ordinary  manner  (Fig.  33),  or  a  fixation 
brace  may  be  worn.  A  long  double  spica  plaster  support  of 
which  the  upper  part  is  cut  away  to  permit  inspection  is  a 
satisfactory  treatment  if  the  contractions  are  spasmodic  and 
painful. 

Counterirritation  at  the  seat  of  disease  was  by  Pott  con- 
sidered of  the  greatest  value,  and  the  application  of  the  actual 
cautery  from  time  to  time,  about  the  kyphosis,  seems  in  certain 
cases  to  exert  a  favorable  influence  on  the  underlying  disease. 


TUBERCULOUS    DISEASE    OF    THE    SPINE.  123 

Electricity,  particularly  galvanism,  has  been  used,  and  it  is 
of  some  service  in  preserving  the  nutrition  of  the  limbs.  Its 
value  in  a  case  must  be  judged  by  its  effect. 

Internal  remedies  are  of  little  value  with  the  possible  excep- 
tion of  iodide  of  potassium,  which  is  supposed  to  act  upon  the 
tuberculous  granulation  tissue  as  upon  the  products  of  syphilitic 
disease.  A  convenient  method  of  administration  is  a  solution 
of  which  one  drop  represents  one  grain  of  the  drug.  This  is 
given  in  milk  or  in  Vichy  water,  beginning  with  five  drops  three 
times  daily  and  increasing  the  dose  a  drop  each  day  until  the 
point  of  toleration  is  reached. 

The. first  indication  of  improvement  is  usually  lessening  of 
the  muscular  rigidity;  then  the  ability  to  move  a  toe  may  be 
regained,  after  which  recovery  follows  quickly.  At  this  stage 
massage  of  the  limbs  may  be  employed  with  advantage.  The 
exaggerated  refiexes  may  persist  long  after  recovery;  in  fact, 
as  has  been  stated  this  symptom  is  not  uncommon  among 
patients  suffering  from  dorsal  Pott's  disease  who  have  never 
been  paralyzed. 

Operative  Treatment. — The  operation  of  laminectomy  was 
at  one  time  in  favor,  but  it  has  now  been  practically  abandoned, 
as  a  treatment  of  routine  at  least,  for  the  paraplegia  of  Pott's 
disease,  because  it  has  been  proved  that  recovery,  if  somewhat 
long  deferred,  is  the  rule  without  operation,  while  the  direct 
death-rate  of  the  operation  is  large. 

In  134  cases  collected  by  Ehein^  the  immediate  mortality 
(those  dying  within  a  month  after  the  operation)  was  36  per 
cent. 

Lloyd^  has  collected  128  "reliable"  cases  of  Pott's  disease 
in  which  laminectomy  was  performed.  The  deaths  due  directly 
to  the  operation  were  21  (16.45  per  cent.)  ;  subsequent  deaths, 
36  (28.20  per  cent.);  total  deaths,  57  (44.55  per  cent.);  re- 
coveries, 37  (28  per  cent.)  ;  improved,  16  (12.5  per  cent.)  ; 
unimproved,  18  (14.06  per  cent.).  Of  eight  cases  operated  by 
Trendelenburg  in  1889  six  were  living  and  well  in  1905.  One 
was  unimproved.^ 

Laminectomy  is  an  incomplete  operation  in  the  sense  that 

the  disease   of  the  bone   is  not   removed,   thus   recurrence   of 

paralysis  from  extension  of  the  disease  is  not  infrequent  after  a 

successful  immediate  result.     It  should  be  reserved  for  those 

^Willard,  Journal  of  Nervous  and  Mental  Disease,  •  May,  1897. 
-  Philadelphia  Medical  Journal,  February  22,  1902. 
^  Sultan,  Zeitsch.  f .  Chir.,  v.  Ixxviii.,  1  and  2. 


124  OBTHOPEDIC    SURGEBY. 

cases  in  which  after  a  thorough  and  prolonged  trial  of  ordinary 
methods  the  condition  does  not  improve.  Eighteen  months  has 
been  suggested  as  the  proper  time  in  which  to  test  conservative 
treatment.  The  operation  may  be  indicated  also  if  the  symp- 
toms, in  spite  of  treatment,  increase  in  severity,  particularly 
when  the  cervical  region  is  involved  or  when  there  is  evidence 
that  the  integrity  of  the  cord  is  threatened,  or  when  the  paraly- 
sis is  of  sudden  onset,  or  when  displacement  of  bone  or  pres- 
sure from  an  abscess  seems  probable  as  the  exciting  cause, 
although  in  the  latter  instance  the  direct  evacuation  of  the  ab- 
scess by  costotransversectomy,  as  advocated  by  Menard,  should 
precede  laminectomy.  Occasionally,  the  operation  is  indicated 
as  a  forlorn  hope  in  adults  suffering  from  cystitis  and  bed-sores. 

The  usual  method  in  operating  is  as  follows  :^  A  long  incision 
is  made  parallel  to  and  close  by  the  side  of  the  spinous  processes. 
The  muscles  are  drawn  to  one  side,  the  spinous  processes  are  cut 
through  and  drawn  with  the  attached  muscles  to  the  opposite 
side.  The  laminae  at  the  seat  of  disease  are  then  removed  with 
the  cutting  forceps,  exposing  the  dura  mater.  The  tuberculous 
tissue  is  usually  found  upon  the  front  or  lateral  surfaces  of  the 
canal,  and  its  complete  removal  is  often  impossible.  The  shock 
of  the  operation  is  often  marked,  so  that  it  should  be  as  rapid 
as  possible,  and  loss  of  blood  should  be  carefully  guarded 
against.  As  a  rule,  the  wound  may  be  closed  without  drainage. 
After  the  operation  the  spine  should  be  supported  by  the  brace 
or  jacket  until  the  disease  is  cured. 

In  several  instances  forcible  correction  of  the  spine  (Calot's 
operation)  relieved  the  pressure  on  the  cord  and  rapid  recover}^ 
followed.  This  indicates  the  importance  of  assuring  overexten- 
sion of  the  spine  whenever  it  is  possible,  but  this  should  be 
attained  preferably  by  gradual,  postural  correction  rather  than 
by  force. 

Fortunately,  the  great  majority  of  cases  of  paraplegia  from 
Pott's  disease  occur  in  childhood,  and,  as  has  been  mentioned, 
the  complications  of  later  life,  bed-sores,  cystitis,  and  the  like, 
are  rarely  troublesome.  Such  paralysis  in  the  adult  is  more 
serious  from  every  point  of  view.     The  principles  of  treatment 

^  It  should  be  borne  in  mind  that  the  segments  of  the  cord  do  not  cor- 
respond to  the  spinous  processes  of  the  same  number.  Thus,  in  the  cervical 
region  the  affected  segment  is  one  vertebra  higher.  In  the  upper  dorsal 
region  two  higher.  From  the  sixth  to  eleventh  dorsal  three  higher.  The 
three  lower  lumbar  and  sacral  segments  are  to  be  found  opposite  the  eleventh 
and  twelfth  dorsal  spines.      (Chipault.) 


TUBEECULOUS    DISEASE    OF    THE    SPINE,  125 

are  the  same,  but  their  application  is  more  difficult  and  the 
prognosis  is  more  doubtful. 

Local  Paralysis  Complicating'  Pott's  Disease. — In  certain 
cases  the  extension  of  the  disease  may  involve  the  nerve  roots 
near  their  exit  from  the  spine.  This  may  occur  with  or  indepen- 
dently of  the  involvement  of  the  cord.  The  symptoms  are  those 
of  neuritis  in  the  affected  nerves.  In  extremely  rare  instances 
the  pressure  on  the  cord  may  cause  hemiplegia. 

The  Duration  of  the  Treatment  of  Pott 's  Disease. — The  dura- 
tion of  the  treatment  must  depend  upon  the  extent  and  severity 
of  the  disease.  It  may  be  divided  into  two  periods :  one  during 
which  the  disease  is  active,  when  fixation  is  indicated,  and  a 
stage  of  recovery,  during  which  supervision  is  required.  Dur- 
ing the  first  stage  the  destructive  process  may  increase  the  direct 
deformity;  during  the  later  period  of  weakness  the  distortion 
may  increase,  simply  because  of  the  general  inclination  toward 
deformity  and  because  of  the  atrophy  of  the  supporting  muscles. 

Tuberculosis  of  the  spine  is  slow  in  its  progress,  and  re- 
covery is  often  insecure.  The  course  of  the  disease  is  shortest 
in  the  cervical  region,  but  even  here  two  years  of  brace  treat- 
ment will  probably  be  required,  and  in  the  lower  region  double 
this  time  even  in  the  milder  type  of  cases.  Active  treatment 
should  be  continued  as  long  as  there  is  evidence  of  disease.  The 
absence  of  actual  pain  and  discomfort  is  of  little  value  in  de- 
termining the  absolute  cure  if  braces  have  been  employed.  The 
absence  of  muscular  spasm  is  more  significant,  since  it  usually 
persists  as  long  as  the  disease  is  active.  The  presence  of  pain 
on  passive  motion  or  muscular  contraction  or  abscess  would,  of 
course,  indicate  the  necessity  of  further  treatment. 

Direct  palpation  is  of  some  value  in  determining  the  condi- 
tion of  the  affected  part.  During  the  progressive  stage,  careful, 
deep  pressure  over  the  spinous  processes  may  show  greater 
mobility  of  those  involved  in  the  disease.  During  the  stage  of 
repair  and  consolidation  the  mobility  is  replaced  by  rigidity. 
The  appearance  of  the  kyphosis  has  some  significance.  In  the 
early  stage  of  the  disease  its  area  is  not  clearly  defined,  but 
when  consolidation  has  taken  jAace  its  extent  is  shown  by  the 
rigid  vertebrse,  which  stand  out  separated  from  the  remainder 
of  the  spine  by  a  well-marked  sulcus,  which  is  much  deeper 
below  than  above  the  kyphosis. 

Even  when  the  disease  appears  to  be  cured,  removal  of  sup- 
port should  be  tentative;  the  jacket  should  be  replaced  by. the 


126  OETHOPEDIC    SUEGEEY. 

corset,  or  the  brace  hy  a  lighter  appliance ;  then  support  mav 
be  removed  at  night,  later  for  part  of  the  dav,  and  at  last,  after 
many  months,  it  may  be  discarded.  Then  may  follow  massage 
of  the  atrophied  muscles  of  the  trunk  and  gentle  exercise. 

Such  careful  supervision  must  be  continued  for  a  much  longer 
time  if  the  best  ultimate  result  is  to  be  attained,  for,  as  has 
been  mentioned,  one  should  guard  against  the  secondary  dis- 
tortions, which  may  be  due  simply  to  weakness  and  to  the  un- 
favorable mechanical  conditions  induced  by  the  primary  de- 
formity. If  curvatures  of  the  spine  are  so  common  among 
normal  individuals  how  much  more  likely  is  deformity  to  in- 
crease when  the  trunk  has  been  weakened  by  disease  and  by 
long  disuse  of  the  muscles. 

This  secondary  increase  of  deformity  is  not  so  much  to  be 
feared  after  the  cure  of  the  disease  in  the  lumbar  region,  be- 
cause of  the  favorable  attitude  of  erectness,  nor  is  it  likely  to 
be  marked  after  cure  in  the  cervical  region  of  the  spine ;  but  in 
disease  of  the  upper  and  middle  dorsal  region  support  must  be 
continued  long  after  recovery,  and  supervision  must  be  exercised 
until  after  the  period  of  adolescence,  if  increase  of  the  deformity 
is  to  be  prevented. 

Recurrence  of  Disease  and  Later  Effects  of  Deformity. — The 
disease  may  recur  after  an  inter^^al  of  many  years  of  apparent 
cure,  and  such  recurrences  are  often  accompanied  by  the  forma- 
tion of  an  abscess  or  by  paralysis. 

If  recovery  from  Pott's  disease  has  been  complete,  and  if  de- 
formity has  been  prevented,  the  condition  of  the  patient  is  to 
all  intents  normal ;  but  if  the  course  of  the  disease  has  been  pro- 
longed, and  if  the  deformity  is  great,  his  condition  is  abnormal. 
He  is  unfitted  for  ordinary  occupations,  and  comparative  com- 
fort is  assured  only  by  constant  care.  Such  individuals  are 
likely  to  suffer  from  neuralgic  pain  about  the  weakened  spine 
on  overexertion  or  whenever  the  general  condition  is  depressed 
from  any  cause.  In  such  cases  the  use  of  some  form  of  light 
corset  adds  to  the  comfort  of  the  patient. 

In  certain  instances  pain  localized  in  the  lateral  region  of  the 
trunk  may  be  caused  by  compression  of  an  intercostal  nerve,  or 
it  may  be  due  to  compression  of  the  tissues  between  the  last  rib 
and  the  pelvis.  In  several  cases  of  this  character  reported  by 
Goldthwait,  resection  of  a  portion  of  a  rib  at  the  seat  of  pain 
relieved  the  discomfort. 

Secondary  Deformities.. — AVhile  the  patient  is  under  treatment 


TUBEBCULOUS    DISEASE    OF    THE    SPINE.  127 

for  Pott's  disease  one  should  be  on  the  alert  to  prevent  other 
deformities  that  may  follow  the  general  weakness  and  restric- 
tion of  normal  functions.  One  of  these  is  the  weak  foot,  some- 
times called  weak  ankle  or  flat-foot,  and  with  it  is  often  asso- 
ciated a  moderate  degree  of  knock-knee.  This  may  be  pre- 
vented by  a  shoe  of  proper  shape,  of  which  the  heel  and  sole  are 
thickened  slightly  on  the  inner  side. 


CHAPTER  II. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE. 


SYPHILIS. 

Syphilis^  in  the  inherited  or  in  the  later  stages  of  the  ac- 
quired form,  may  affect  the  bones  of  the  spine  and  cause  local 

deformity  and  symptoms  that  can- 
not be  distinguished  from  those  of 
Pott's  disease. 

Diagnosis. — As  compared  with 
tuberculosis  it  is  a  rare  disease  of 
the  spine.^  Its  manifestations  are 
likely  to  be  general  in  character, 
the  deformity  of  the  spine  being 
but  one  of  many  evidences  of 
disease. 

If  syphilis  were  limited  to  the 
spine  and  simulated  the  symptoms 
and  the  deformity  of  Pott's  disease 
it  would  de^mand  the  same  local 
treatment.  Specific  remedies  are 
indicated  if  one  suspects  the  pres- 
ence of  syphilitic  taint,  even  if  the 
local  disease  appears  to  be  tubercu- 
lous in  character. 

MALIGNANT    DISEASE    OF    THE 
SPINE. 


Vertical  anteroposterior  section 
of  the  lumbar  spine,  showing  de- 
posit of  gumma  in  the  posterior 
part  of  the  third  and  fourth 
vertebrae.    (After   Fournier.) 


Malignant  disease  of  the  spine 

is  a  rare  affection,  particularly  so 

in  childhood.     Sarcoma  is  more  common  than  carcinoma,  and 

it  may  affect  the  spine  primarily.     Carcinoma  is  almost  always 

secondary  to  a  primary  tumor  elsewhere,  the  spine  becoming 

involved  by  metastasis  or  by  contiguity.     Schlesinger-  in  3720 

cases  of  carcinoma  found  secondary  growths  in  the  spine  in  54. 

1  Jasinski,  Archiv  f.  Dermat.  u.  Sypli.,  Bd.  xxiii.,  S.  400. 
"Buckley,  Journal  of  Nervous  and  Mental  Disease,  April,  1902. 

128 


NON-TUBEECULOUS  AFFECTIONS  OF  THE  SPINE.         129 

Diagnosis. — Malignant  disease  differs  from  tuberculosis  of 
the  spine  in  that  its  symptoms  are  usually  more  severe ;  the  pain 
is  usually  persistent,  and  it  is  not  relieved  by  support  or  recum- 
bency, as  is  that  of  Pott's  disease.  The  constitutional  symptoms 
are  more  marked  and  the  steady  progress  of  the  disease  toward 
a  fatal  termination  is  soon  apparent.  Locally,  the  angular  de- 
formity is  usually  slight,  and  it  may  be  absent.  ISTot  infre- 
quently the  tumor  may  be  palpated  through  the  abdominal  wall. 

Paralysis  is  a  frequent  and  often  an  early  symptom,  usually 
affecting  sensation  as  well  as  motion. 

As  has  been  stated,  carcinoma  is  almost  always  secondary  to 
disease  elsewhere.  In  20  per  cent,  of  150  fatal  cases  of  cancer^ 
the  spine  was  involved  and  in  about  half  the  cases  the  diagnosis 
had  been  made  before  autopsy.  Thus,  if  after  the  operation  for 
the  removal  of  carcinoma  symptoms  of  disease  of  the  spine 
appear  one  should  suspect  this  complication. 

Malignant  disease  of  the  spine  is  a  fatal  affection,  and  the 
treatment  can  be  but  palliative. 

ACUTE  OSTEOMYELITIS  OF  THE  SPINE. 

Infectious  osteomyelitis  of  the  spine  is  comparatively  un- 
common, about  100  cases  having  been  recorded.^  The  bodies 
of  the  vertebrae  are  usually  involved,  exceptionally  the  arches 
or  other  parts. 

Symptoms. — The  symptoms  are  similar  to  those  of  acute  in- 
fectious processes  elsewhere,  and  are  characterized  by  sudden 
onset,  with  pain,  fever,  and  constitutional  depression.  There 
are  local  pain  and  sensitiveness  about  the  spine  and  in  many 
instances  distention  of  the  veins  in  the  neighborhood  caused 
by  interference  with  the  circulation  by  septic  thrombosis.  Ab- 
scess quickly  forms,  and  paralysis  from  the  rapid  extension  of 
the  disease  is  a  common  complication.  The  symptoms  due  to 
pyogenic  infection  and  to  deep-seated  abscess  are  often  pygemic 
in  character  and  necrosis  of  the  affected  vertebral  bodies  may 
result  in  the  formation  of  large  sequestra. 

In  sixty-one  cases  collected  from  literature,^  the  situation  of 
the  disease  was  as  follows: 

^  Berrenberg-Gassler,  Zeitsch.  f.  Chir.  u.  Mechan.  Orth.,  Jaiiy.,  1910. 
^Kirmisson,  Presse  Med.,  1909,  n.  38. 
^Himt,  Medical  Eecord,  April  23,  1904. 

9 


130  OBTHOFEDIC   SURGERY. 

Cervical  region 12 

Thoracic  region    15 

Lumbar  region   24 

Sacral  region 10 

The  cause  of  the  infection  in  fifteen  of  the  twenty  cases  ex- 
amined was  the  Staphylococcus  aureus.  Injury  is  a  predispos- 
ing cause. 

In  forty  of  fifty-six  cases  reported/  the  patient  died  of  gen- 
eral infection,  pleuropneumonia,  or  meningitis  before  the  diag- 
nosis was  made  and  before  abscess  had  appeared.  The  mor- 
tality was  about  56  per  cent. 

Recovered.  Died. 

Suboccipital  region   1  4 

Cervical 2  2 

Dorsal 7  3 

Lumbar    13  15 

Sacral  _0  _6 

23  30 

A  more  localized  and  more  chronic,  and  of  course  far  less 
dangerous,  form  of  osteomyelitis  may  occur,  and  abscess  may  be 
the  first  sign  of  the  disease.  In  all  cases  of  this  character, 
whether  acute  or  chronic,  other  bones  or  joints  or  other  tissues 
are  often  involved,  and  in  many  instances  an  infected  wound  or 
discharging  ear,  for  example,  may  indicate  the  source  of  in- 
fection. 

Treatment. — The  treatment  consists  in  the  immediate  evacu- 
ation and  drainage  of  the  abscess,  the  removal  of  the  necrosed 
bone  if  possible,  and  in  supporting  the  spine  during  the  subse- 
quent stage  of  weakness. 

ACTINOMYCOSIS    OF    THE    SPINE. 

Actinomycosis  of  this  region  is  extremely  uncommon,  the 
spine  having  been  involved  secondarily  in  about  2  per  cent,  of 
the  reported  cases.^  The  diagnosis  may  be  made  by  the  micro- 
scopic examination  of  the  discharge  from  the  sinuses  that  almost 
always  form  when  bone  is  affected. 

INJURY  OF  THE  SPINE. 

Severe  strains  or  fractures  may  simulate  disease  very  closely, 
and  in  some  instances,  particularly  of  injury  of  the  cervical 

^  Grisel,  Eevue  d'orthopedie,  September,  1903. 

-  Erving,  Johns  Hopkins  Bulletin,  November,  1902. 


N  ON -TUBERCULOUS  AFFECTIONS  OF  TEE  SPINE.         131 

region,  the  diagnosis  is  practically  impossible  until  after  treat- 
ment by  support  and  fixation  has  been  applied,  when,  as  a  rule, 
if  disease  is  absent,  the  symptoms,  even  though  of  long  standing, 
quickly  subside.-^ 

Fracture  of  the  spine  in  the  middle  region  may  cause  angu- 
lar deformity,  and  in  untreated  cases  symptoms  of  pain  and 
weakness,  similar  to  those  of  Pott's  disease,  may  persist  in- 
definitely. 

Crushing  of  one  or  more  of  the  vertebral  bodies  without  dis- 
placement and  without  severe  immediate  symptoms,  other  than 
the  slight  deformity,  may  be  the  result  of  injury,  especially  falls 
from  a  height.  These  cases  are  not  uncommon,  and  as  the 
severity  of  the  injury  is  not  often  recognized,  th3  local  de- 
formity, which  may  not  attract  attention  until  several  weeks 
after  the  accident,  combined  with  stiffness  and  weakness,  may 
be  mistaken  for  Pott's  disease. 

Rupture  of  spinal  ligaments  may  be  caused  by  forcible  flexion 
of  the  spine.  The  resulting  deformity  and  weakness  resemble 
the  symptoms  caused  by  a  crush  of  one  of  the  vertebral  bodies.^ 

Traumatic  Spondylitis. — KummelP  has  described  a  form  of 
rarefying  ostitis  of  the  spine  apparently  caused  by  injury.  It 
is  characterized  by  symptoms  of  pain  and  weakness  referred  to 
the  back,  and  by  a  pronounced  rounded  kyphosis  of  the  dorsal 
region.  Motor  disturbances  of  the  lower  extremities  are  fre- 
quent. .  This  is  easily  explained  by  the  fact  that  in  case's  of  this 
character  fracture,  disorganization  of  the  disks,  rupture  of  liga- 
ments, hemorrhage  beneath  the  longitudinal  ligament,  into  the 
muscles  or  into  the  spinal  canal,  have  been  demonstrated  at 
autopsy.  Indirect  injury,  shock  to  the  nervous  apparatus  and 
the  like  may  cause  complicating  symptoms  in  addition.^ 

Kummell's  cases  do  not  differ  particularly  from  those  of 
injury  that  have  been  described.  In  fact,  in  the  neglected  cases 
of  injury  of  the  spine  the  pain  and  weakness  may  persist  indefi- 
nitely, and  the  deformity  may  increase.  In  certain  instances 
there  may  be  a  secondary  infection,  tuberculous  or  otherwise, 
at  the  seat  of  injury,  and  in  others  the  injury  may  be  the  excit- 
ing cause  of  spondylitis  deformans,  but  such  results  are  unusual. 

^  Mixter  and  Osgood,  J.  Am.  Orth.  Assn.,  Feby.,  1910. 
2  Painter  and  Osgood,  Boston  Medical  and  Surgical  Journal,  January  2, 
1902. 

'Deutsche  med.  Woch.,  1895,  No.  11. 

^  Eeuter,  Archiv  f .  Orth.  u.  Unfallchirurgie,  B.  ii.,  H.  2,  1904. 


132  OETHOPEDIC  SUPiGEBY. 

Treatment. — In  all  such  cases,  and  whenever  weakness  of 
the  spine  persists,  and  if  motion  causes  pain,  a  support  should 
be  applied  as  in  the  treatment  of  Pott's  disease.  If  possible, 
deformity  if  of  recent  origin  should  be  corrected  in  suitable 
cases  by  gentle  manipulation  under  anaesthesia.  In  others,  by 
recumbency  and  hyperextension  or  by  the  Calot  jacket.  Massage 
and  graduated  exercises  are  of  value  during  the  period  of  recovery. 
Clinical  evidence  indicates  that  repair  is  slow :  support,  there- 
fore, should  be  continued  for  at  least  six  months  and  for  a  much 
longer  time  if  the  injury  is  of  the  middle  dorsal  region  where 
the  tendency  to  postural  deformity  is  so  marked. 

INFECTIOUS   DISEASES    OF    THE    COVERINGS    OR   ARTICU- 
LATIONS OF   THE   SPINE. 

The  "  Typhoid  Spine." — During  the  course  of  or  during  con- 
valescence from  typhoid  fever,  and  occasionally  after  apparent 
recovery  from  the  disease,  symptoms  of  pain,  weakness,  and 
stiffness  of  the  back  may  appear.  These  are  caused  apparently 
by  secondary  infection  of  the  fibrous  coverings  and  articula- 
tions of  the  spine,  similar  to  the  more  common  but  more  severe 
forms  of  periostitis  of  the  tibia  or  other  bones,  from  the  same 
cause.  There  is  usually  pain  on  motion,  reflected  along  the 
nerves.  In  some  instances  this  is  extreme,  and  there  may  be 
accompanying  muscular  "  cramps  "  in  the  limbs,  local  muscular 
spasm,  and  pain  on  pressure  over  the  affected  vertebrae.  The 
temperature  is  often  above  normal,  with  irregular  and  sometimes 
extreme  fluctuations  in  severe  cases. 

In  many  instances  a  neurotic  element  is  present,  induced, 
doubtless,  by  the  preceding  disease.  The  complication  is  most 
common  in  young  adults. 

In  six  of  sixty-eight  cases  tabulated  by  Wurtz^  the  patients 
were  children,  and  several  of  this  class  have  come  under  my 
observation. 

Diagnosis.- — The  diagnosis  is  usually  made  clear  by  the  history 
of  the  disease  of  which  it  is  a  complication. 

Treatment.. — The  treatment  should  be  symptomatic.  During 
the  active  stage,  if  pain  is  severe,  the  patient  should  be  kept  in 
the  recumbent  position,  if  necessary  on  the  stretcher  frame. 
Locally,  the  application  of  the  Paquelin  cautery  is  of  service. 
As  soon  as  is  practicable  a  back  brace  or  other  support  should 

•Boston  Medical  and  Surgical  Journal,  June  26,  1902. 


NON-TUBESCULOUS  AFFECTIONS  OF  THE  SPINE.         133 

be  a23.plied,  which  should  be  worn  until  the  symptoms  have 
subsided.  Complete  recovery  is  the  rule,  the  duration  of  the 
symptoms  averaging  about  six  months.  Slight  restriction  of 
motion  may  persist  in  the  more  severe  type  of  cases. 

This  description  applies  particularly  to  a  class  of  cases  of  a 
mild  type  described  by  Gibney^  as  typhoid  spine.  Disease  of 
the  spine  complicating  typhoid  fever  was  first  described  by 
Maisonneuve  in  1835.  Terrillon^  classifies  the  lesions  of 
typhoid  infection  of  the  spine  as : 

1.  Simple  periostitis. 

2.  Periostitis  with  subperiosteal  abscess. 

3.  Periostitis  with  ostitis. 

In  eight  of  twenty-six  cases  investigated  by  LorcF  local  de- 
formity indicated  a  destructive  process. 

Other  Forms  of  Infectious  Disease. — Symptoms  resembling 
those  described  may  follow  other  forms  of  contagious  disease, 
notably  scarlatina,  but,  as  a  rule,  they  are  much  less  persistent 
and  less  severe. 

"  Gonorrhceal  rheumatism  "  of  the  spine  is  uncommon.  Its 
symptoms  and  pathology  resemble  those  of  the  typhoid  spine. 
Anchylosis  is,  however,  more  common  as  a  result  than  after 
other  forms  of  infection;  in  fact,  gonorrhcea  is  apparently l)ne 
of  the  more  common  causes  of  spondylitis  deformans.         m 

Treatment. — The  tre.atment,  aside  from  that  of  the  exclcing 
cause,  is  symptomatic.  Local  support  is  indicated  in  many 
instances.  f 

Arthritis  of  the  Suboccipital  Region. ^ — The  articulations  of 
the  occipitoaxoid  region  are  sometimes  aifected  by  what  appears 
to  be  a  form  of  acute  or  subacute  infectious  or  toxic,  arthritis 
similar  in  characteristics  to  acute  rheumatism.  It  may  follow 
tonsillitis,  diphtheria,  or  other  contagious  disease.  It  may  be 
distinguished  from  tuberculous  disease  by  its  acute  onset  and 
from  acute  torticollis  by  the  fact  that  all  motions  are  restricted. 

Treatment. — The  treatment  consists  in  support  preferably  of 
the  jury-mast  type  during  the  acute  stage,  followed  by  massage,, 
manipulation,  and  exercise  to  overcome  the  subsequent  stiffness. 

Spondylitis  Deformans. — Synonyms. — Osteoarthritis  of  the 
spine ;  spondylose  rhizomelique ;  stiffness  of  the  vertebral 
column. 

^  Gibney,  Tr.  Am.  Orth.  Assoc,  v.  ii. 

=  Le  Prog.  Med.,  April  12,  1884. 

^  Boston    Medical   and    Surgical   Journal,   June   26,    1905. 


134 


ORTHOPEDIC  SUEGEBT. 


Spondylitis  deformans  is  chronic  progressive  disease  of  the 
spine  terminating  in  anchylosis  and  deformity. 

Pathology.. — The  disease  is  apparently  a  chronic  inflammation 
affecting  primarily  the  ligaments  and  the  periosteal  coverings 
of  the  spine,  a  form  of  ossifying  periostitis  which  binds  the  ver- 
tebr£e  firmly  to  one  another  (Fig.  80).  It  may  begin  on  the 
lateral  or  on  the  anterior  aspect  of  the  spine;  it  may  be  limited 


Fig.  80. 


Spondylitis  deformans   (osteoarthritis).     (Goldthwait.) 

to  a  particular  region,  but  in  most  instances  it  eventually  in- 
volves the  entire  spine  and  often  the  articulations  of  the  ribs  as 
well.  The  intervertebral  disks  atrophy  and  the  spine  becomes 
anchylosed.  In  some  instances  the  margins  of  the  cartilages 
proliferate  and  become  ossified  in  a  manner  characteristic  of 
osteoarthritis  of  the  joints. 

Under  the  general  term  of  spondylitis  deformans  are  in- 
cluded, clinically,  several  varieties  of  disease,  for  example : 

1.  The  affection  of  the  spine  may  be  simply  one  of  the  mani- 


NON-TUBEECULOUS  AFFECTIONS  OF  THE  SPINE. 


135 


festations     of     chronic     atrophic     polyarthritis^"  rheumatoid 
arteritis  "  of  the  spine. 

2.  The  spine  may  be  involved  together  with  one  or  more  of 
the  adjacent  joints  v^hich  present  the  characteristic  symptoms  of 
the  so-called  hypertrophic  form  of  arthritis  deformans — osteo- 
arthritis of  the  spine.  This  form  has  been  designated  by  Marie 
spondylose  rhizomelique    (from  spondylos,  spine;   rhizo,  root; 

Fig.  81. 


■_^^^Sjs«                                             .If,,, 

■■ 

' 

|HH^^^^Kr'}|-:^ 

J 

P 

Spondylitis  deformans,  stiowing  the  characteristic  curvature  of  the  spine.  Age 
of  the  patient,  twenty-three  years.  Duration  of  the  disease  three  years ;  cause 
unlinown.     No  other  joints  involved. 


and  melos,  extremity),  signifying  a  disease  of  the  spine  together 
with  the  adjoining  "root"  joints.^ 

3.  The  disease  may  be  limited  to  the  spine,  and  in  such  cases 
it  appears  to  be  clinically  distinct  from  characteristic  general 
arthritis  or  atrophic  or  hypertrophic  arthritis.  It  may  follow 
acute  polyarthritis,  it  may  be  induced  apparently  by  gonorrhoea 
or  by  other  forms  of  infection,  or  by  injury — "  traumatic  sjDon- 
^  Marie,  Eevue  de  Med.,  1898,  vol.  xviii. 


136 


OBTHOPEDIC    SUBGEBY. 


dylitis."  It  may  begin  acutely,  or  it  may  be  chronic  in  charac- 
ter and  progress  slowly.^  It  may  be  limited  to  a  particular  sec- 
tion of  the  spine,  although,  as  a  rule,  the  other  regions  are 
progressively  involved. 


Fig.  82. 


Fig.  83. 


Spondylitis  deformans,  illus- 
trating the  characteristic  deform- 
ity. Age  of  the  patient,  thirty 
years.  Spine  rigid,  with  the  ex- 
ception of  the  occipitoaxoid  artic- 
ulation. Duration  two  years ; 
cause  unknown.  No  joints  in- 
volved. 


Spondylitis  deformans  in  a  child. 


The  last  class  of  limited  spondylitis  is  more  often  seen  in 
young  adults  from  tv^enty  to  forty  years  of  age,  and  in  at  least 
80  per  cent,  of  the  cases  the  patients  are  males. 

Symptoms. — In  the  ordinary  cases  there  is  usually  an  acute 
onset  from  which  the  patient  dates  the  beginning  of  his  trouble, 

^  Beebterew,  Neurol.  Centralbl.,  vol.  ii.,  p.  426.  Senator,  Berlin,  kiln. 
Wocben.,  November  20,  1897. 


NON-TUBEBCULOUS  AFFECTIONS  OF  TEE  SPINE.         137 

often  so-called  lumbago,  followed  by  a  gradually  increasing  stiff- 
ness of  the  spine  and  accompanying  deformity.  The  patient 
complains  of  stiffness,  weakness,  pain  in  the  loins,  and  of  pain 
radiating  forward  along  the  ribs ;  sometimes  of  weakness  in  the 
limbs,  headache,  nervousness,  and  the  like — symptoms  that  may 
be  explained  in  part  by  the  inflammatory  process  and  by  impli- 
cation of  the  nerve  roots,  and  in  part  by  an  accompanying  neu- 
rasthenia. The  direct  symptoms  are  increased  by  jars,  which 
are  exaggerated  by  the  inelasticity  of  the  spine.  The  disease  is 
usually  progressive,  and  terminates  finally  in  complete  rigidity 
of  the  spine,  which  is  bent  into  a  long  kyphosis,  most  marked 
in  the  upper  dorsal  region,  the  lumbar  lordosis  being  obliterated 
in  many  instances  (Fig.  82). 

The  straightening  of  the  spine  in  the  middle  and  lower  region 
exaggerates  the  forward  thrust  of  the  neck,  and  in  some  in- 
stances the  patients  complain  of  a  disturbance  of  equilibrium, 
especially  of  a  tendency  to  fall  forward. 

When  the  disease  is  limited  to  the  spine  or  to  the  spine  and 
one  or  more  of  the  larger  joints,  the  occipitoaxoid  articulations 
are  not  usually  involved ;  but  in  the  general  form  of  the  disease 
— "rheumatoid  arthritis" — they  are  often  primarily  affected. 
The  types  of  the  disease  may  be  illustrated  by  a  brief  descrip- 
tion of  cases  recently  under  observation. 

Type  I.  ''Rheumatoid  Arthritis''  of  the  Spine. — In  this 
case,  that  of  a  boy  ten  years  of  age,  there  was  characteristic 
general  chronic  (atrophic)  arthritis  that  involved  nearly  every 
joint  of  the  body.  The  entire  spine,  even  including  the  occipito- 
axoid joints,  was  rigid  and  the  head  was  fixed  in  an  attitude  of 
extreme  torticollis. 

Type  II.  "  Osteoarthritis  of  the  Spine"  ("  spondylose  rhizo- 
melique").— A  man  aged  forty-six  years,  after  repeated  attacks 
of  so-called  rheumatism  involving  the  larger  joints,  gradually 
became  disabled  because  of  pain  and  stiffness  of  the  back  and 
because  of  his  inability  to  stand  erect.  In  this  case  there  was 
complete  anchylosis  of  the  spine,  except  of  the  small  joints  of 
the  cervical  region,  and  in  addition  the  right  thigh  was  flexed 
upon  the  body  at  such  an  angle  that  the  patient  could  walk  only 
with  an  exaggerated  stoop.  The  joints  of  the  feet  were  slightly 
involved  also.  ISTo  cause  other  than  exposure  to  cold  and  damp- 
ness could  be  assigned.  The  symptoms  were  of  two  years'  dura- 
tion, periods  of  comfort  alternating  with  disabling  attacks  of 
"  rheumatism." 


138  OBTHOPEDIC    SUEGEEY. 

Type  III.  Spondi/Jitis  Deformans. — Tlie  spine  of  this  pa- 
tient, a  man  aged  forty-six  years,  was  absolutely  anchylosecl  in 
the  characteristic  position.  The  occipitoaxoid  joints  were  not 
involved.  Fourteen  years  before  he  had  suffered  from  a  severe 
and  prolonged  attack  of  ''  inflammatory  rheumatism,"  affecting 
nearly  every  joint,  but  not  the  spine,  and  during  a  succeeding 
period  of  nine  years  he  had  been  disabled  several  times  from  the 
same  cause.  Each  illness  was  coincident  with  gonorrhoea.  Tive 
years  before  examination  the  "  rheumatism '"  had  involved  the 
sj)ine,  and  since  then  he  had  suffered  from  persistent  "  lum- 
bago." Gradually  the  stiffness  of  the  spine  had  increased,  but 
during  this  time  he  had  been  free  from  gonorrhoea,  and  from 
rheumatism  as  well.  The  joints  were  normal  in  appearance 
and  function.  This  patient  suffers  principally  from  nervous- 
ness and  irritability;  he  is  easily  startled;  he  feels  as  if  his 
forehead  was  clasped  by  a  tight  band.  His  direct  symptoms 
are  pain  in  the  loins  and  pain  radiating  under  the  shoulder- 
blades,  increased  by  walking  or  by  jars.  His  equilibrium  is 
disturbed  by  the  forward  projection  of  the  head  and  by  the 
obliteration  of  the  normal  lordosis,  so  that  he  feels  himself 
constantly  inclined  to  fall  forward,  whether  he  is  sitting  or 
standing. 

Ttpe  IV.  In  another  case  very  similar  to  this,  in  a  man  aged 
thirty  years,  the  spine  had  become  rigid  in  a  few  months.  The 
patient  ascribed  the  disease  to  sleeping  out-of-doors.  There 
was  in  this  case  coincident  tuberculous  disease  of  the  lungs. 
And  in  this  instance  the  cause  of  the  deformity  may  have  been 
superficial  tuberculous  disease  or  so-called  tuberculous  rheu- 
matism. 

Type  Y.  A  man  aged  sixty-two  years,  presenting  the  char- 
acteristic deformity  and  symptoms  of  the  subacute  type,  gave 
the  following  account  of  the  affection:  Fifteen  years  before  he 
had  suffered  from  "  chronic  lumbago."  The  pain  and  stiffness, 
at  first  limited  to  the  lower  region  of  the  spine,  had,  with  inter- 
vening periods  of  remission,  gradually  ascended,  and  at  the  time 
of  examination  the  cervical  region  was  the  seat  of  the  more 
active  process.  He  had  been  treated  by  internal  remedies,  by 
baths,  and  by  change  of  climate,  without  avail.  He  knew  he 
had  the  ''"  old  man's  stoop,"  but  he  was  surprised  to  learn  that 
the  cause  of  his  symptoms  was  a  disease  of  the  spine.  The 
spine  was  rigid,  although  not  anchylosed,  as  indicated  by  the 
discomfort  on  changing  from   one   position  to  another.      The 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE.         139 

occipitoaxoid  articulations  and  the  other  joints  were  free  from 
disease. 

This  subacute  form  of  the  affection  is  very  common,  and,  as 
in  this  instance,  the  patients  are  usually  treated  for  rheumatism, 

Fig.  84. 


Extreme  posterior  curvature  of  the  spine   in  adolescence,  sliowing  retraction   of 
the  abdomen.      This  deformity  may  be  mistalien  for  spondylitis   deformans. 


muscular  or  otherwise,  for  many  years  before  the  true  diag- 
nosis is  made. 

Treatment. — The  general  treatment,  dietetic,  climatic  and  the 
like,  should  include  if  possible  the  removal  of  the  exciting 
causes,  persistent  gonorrhoea  in  the  younger  subjects  being  ap- 
parently the  most  common  of  these.  The  local  treatment  is 
symptomatic.  Massage  of  the  muscles,  hot  baths,  and  the  like 
may  add  to  the  comfort  of  the  patient,  but  violent  exercise  or 
passive  movements  of  the  spine  are  harmful.    Support  is  always 


140  ORTHOPEDIC    SUEGEBY. 

indicated  during  the  progressive  stage  of  the  aff.ection,  and  it  is 
the  only  efficient  remedy.  The  support  may  be  in  the  form  of 
a  light  brace  or  jacket.  It  is  particularly  efficacious  when  the 
disease  is  limited  to  the  lower  and  middle  regions  of  the  spine. 
In  such  cases  under  efficient  protection  the  muscular  spasm  sub- 
sides and  motion  returns  in  some  degree.  Even  in  progressive 
cases  one  may  hope  to  preserve  the  lumbar  lordosis,  and  thus 
to  lessen  the  general  effect  of  the  deformity  when  the  spine  be- 
comes rigid.  In  certain  instances  in  which  anchylosis  is  not 
established,  force  may  be  employed  with  caution  to  improve  the 
contour  of  the  spine,  particularly  with  the  aim  of  re-establishing 
the  lumbar  lordosis,  and  thus  enabling  the  patient  to  stand  erect. 
The  patient  learns  by  experience  what  exercises  or  postures 
increase  the  discomfort,  and  these  should  be  avoided  if  possible. 
The  application  of  a  cautery  is  often  of  service,  and  self-suspen- 
sion at  intervals  may  relieve  the  dragging  sensation  in  the 
muscles.  Ruljber  heels  are  useful  in  lessening  the  jar.  As  has 
been  stated,  in  some  cases  the  disease  remains  localized,  but 
ordinarily  it  extends  along  the  spine.  When  a  part  of  the  spine 
becomes  firmly  anchylosed  the  local  discomfort  lessens  or  ceases, 
and  is  transferred  to  the  part  where  the  process  is  still  ad- 
vancing. 

Kyphosis  of  Adolescents. — A  form  of  extreme  kyphosis  ac- 
comjDanied  by  stiffness  and  discomfort  is  sometimes  seen.  It 
appears  to  be  a  static  deformity  induced  by  overwork  in  rapidly 
growing  adolescents,  which  finally  becomes  fixed  by  accommo- 
dative changes  in  the  bones  and  neighboring  tissues.  It  can 
hardly  be  classified  with  spondylitis  deformans,  although  there 
may  be  some  difficulty  in  disting-uishing  between  the  two  (Fig. 
84).  In  favorable  cases  partial  rectification  of  the  deformity 
by  force  (the  Calot  operation)  is  indicated.  Afterward  support, 
forcible  movements,  and  corrective  exercises  should  be  em- 
ployed. 

THE  RHACHITIC  SPINE. 

The  rhachitic  spine  has  been  described  in  the  consideration 
of  the  differential  diagnosis  of  Pott's  disease.  It  usually  de- 
velops during  the  first  or  second  year  of  life,  in  children  who 
sit  the  greater  part  of  the  time ;  it  is,  in  fact,  simply  an  exag- 
geration of  the  contour  that  is  normal  in  the  sitting  posture. 
The  typical  rhachitic  kyphosis  is  thus  a  rounded  projection  of 
the  lower  region  of  the  spine,  which  is  more  or  less  rigid  accord- 
ing to  its  duration.    If  the  deformity  is  extreme  there  may  be  a 


NON -TUBERCULOUS  AFFECTIONS  OF  TEE  SPINE.         141 

compensatory  backward  inclination  of  the  head,  which  may  be 
accompanied  by  contraction  of  the  posterior  group  of  muscles, 
"  cervical  opisthotonos." 

Treatment.^ — Aside  from  the  constitutional  treatment  of  the 
rhachitic  condition,  and  from  the  measures  that  should  be  em- 
ployed to  improve  the  nutrition  of  the  muscles  in  general,  the 

Fig.  85. 


Rhachitic    kyphosis. 

indications  are  to  overcome  the  deformity  and  the  limitation  of 
motion  of  the  spine ;  to  support  it,  if  necessary,  during  the  stage 
of  weakness;  and  to  prevent,  as  far  as  possible,  the  postures  that 
favor  the  distortion. 

The  correction  of  the  deformity  may  be  accomplished  by  mas- 
sage and  by  direct  manipulation  of  the  spine.  The  child  lying 
face  downward,  on  a  table ;  one  hand  is  placed  on  the  projection, 
and  with  the  other  the  legs  are  raised  to  throw  the  spine  into  a 
position  of  overextension.  This  stretching  is  performed  slowly 
and  carefully  over  and  over  again  at  morning  and  night,  and 


142  ORTHOPEDIC  SUEGERY. 

the  manipulation  is  followed  by  tliorongli  massage  of  the 
muscles.  If  the  deformity  is  marked  and  if  the  general  rha- 
chitic  process  is  still  active,  the  recumbent  posture,  on  a  light 
frame,  in  an  attitude  of  overextension  may  be  indicated  as  de- 
scribed in  the  treatment  of  Pott's  disease. 

For  older  subjects  some  form  of  light  back  brace  may  be  suffi- 
cient in  connection  with  the  massage,  and  systematic  correction- 
of  the  deformity. 

The  Natural  Cure. — It  may  be  stated  that  the  rhachitic  spine  is 
to  a  certain  extent  corrected  when  the  erect  posture  is  assumed, 
by  the  inclination  of  the  pelvis  and  accompanying  lordosis. 
This  natural  cure  is,  however,  often  rather  a  distribution  of 
deformity  than  a  cure,  for  the  upper  part  of  the  projection  may 
remain  as  an  exaggeration  of  the  normal  dorsal  kyphosis 
balanced  by  an  exaggerated  lordosis,  ''the  rhachitic  attitude." 
In  other  instances  the  persistence  of  the  lumbar  kyphosis  may 
induce  a  compensatory  flattening  of  the  normal  dorsal  kyphosis. 
Thus,  rhachitis  may  cause  the  so-called  flat  hack  as  well. 

It  may  be  mentioned  that  rotary  lateral  curvature  of  the 
spine,  one  of  the  common  deformities  induced  by  rhachitis,  is 
far  more  serious  than  the  anteroposterior  curvature,  with  which 
it  is  occasionally  combined.  Its  treatment  is  considered  in 
Chapter  III. 

Osteitis  Deformans. — Osteitis  deformans  is  a  general  disease 
characterized  by  hypertrophy  and  softening  of  the  bones.  The 
deformity  of  the  spine  is  similar  to  that  of  spondylitis  de- 
formans, but  the  rigidity  is  not  as  marked,  and  the  discomfort 
is  far  less  than  in  this  affection. 

Tabetic  Deformity  of  the  Spine. — In  rare  instances  deform- 
ity of  the  spine,  either  posterior  or  lateral,  appears  as  a  compli- 
cation of  locomotor  ataxia.  Fifteen  cases  are  recorded.^  These 
diseases  are  described  elsewhere. 

Spondylolisthesis. — Spondylolisthesis  is  a  deformity  in  which 
the  body  of  one  of  the  lower  lumbar  vertebrae,  most  often  the 
fifth,  is  displaced  forward  and  downward  (Fig.  82).  The 
relative  weakness  of  the  ligamentous  support  and  the  inclina- 
tion of  the  upper  surface  of  the  sacrum  favors  displacement 
at  this  point.  In  certain  instances  the  spinous  process  may  re- 
main in  its  normal  position,  while  the  laminae  become  elongated 
or  separated  from  the  body  (Fig.  86).  The  condition  was  first 
described  by  Killian  in  1854,  and  it  was  thoroughly  investi- 
gated by  ISTeugebauer  in  1890. 

'  Cornel],  Bulletin  of  .Johns  Hopkins  Hospital,  October,  1902. 


NON-TUBEBCULOUS  AFFECTIONS  OF  TEE  SPINE. 


143 


The  causes  are  congenital  malformation,  injury,  overstrain, 
or  disease  of  the  lumbosacral  articulation.  Lane  states  that 
slighter  degrees  of  the  deformity  are  often  observed  among 
laborers.     The  trunk  is  displaced  forvs^ard  and  downward  in  its 


Fig.  86, 


Small   pelvis  of  Prague    (median  section).     IlUistrating  slight  forward   displace- 
ment of  the  body  of  the  fifth  lumbar  vertebra.      (Neugebauer.) 

relation  to  the  pelvis.  The  sacrum  rotates  backward  and  the 
inclination  of  the  pelvis  is  lessened  or  lost,  the  space  between  the 
ribs  and  the  iliac  crests  being  correspondingly  diminished.  In 
some  instances  the  contour  of  the  back  is  flat  although  the  trunk 
is  inclined  backward;  in  others  there  is  a  sharp  forward  in- 
clination above  the  projecting  sacrum  (Fig.  87).  Forward 
bending  of  the  spine  is  much  restricted. 

The  typical  deformity  is  most  often  seen  in  women;  and  it 
first  attracted  attention  because  of  its  influence  on  parturition. 
The  usual  symptoms  are  weakness  and  discomfort  in  the  lumbar 
region.  The  gait  is  awkward  and  it  may  be  almost  ataxic  in 
character.  Pain  in  the  lumbar  region  radiating  down  the  limbs 
is  a  common  symptom. 

Treatment. — -In  cases  of  this  type  and  particularly  if  the  de- 
formity is  the  result  of  injury  a  strong  corset  or  back  brace  of 
the  Knight  or  Taylor  type  is  indicated.  For  the  mild  congenital 
cases  seen  in  young  subjects  exercise  to  prevent  the  limitation  of 
flexion,  and  the  avoidance  of  postures  that  favor  deformity  are 
usually  efiicacious  in  checking  the  progress  of  the  distortion  and 
in  relieving  the  weakness  and  awkwardness  that  it  induces. 


144 


OBTHOPEDIC  SUBGEBY. 


Fig.  8( 


PAIN  IN  THE  LOWER  PART  OF  THE  BACK. 

Discomfort  in  the  lumbar  region  of  the  character  of  tire, 
weakness,  or  even  of  actual  pain  are  sometimes  an  accompani- 
ment of  disease  or  of  displacement  of  the  pelvic  or  abdominal 

organs.  Pain  in  this  region  is  also 
a  common  symptom  among  over- 
worked women.  It  may  be  induced 
also  by  weakness  or  deformity  of  the 
feet.  It  is  often  present  if  the  lum- 
bar lordosis  is  exaggerated  tempo- 
rarily, as  by  the  wearing  of  high 
heels,  or  permanently,  as  a  compen- 
satory deformity  for  dorsal  Pott's 
disease,  or  because  of  flexion  of  the 
thigh  after  hip  disease. 

As  a  result  of  strain  or  other  in- 
jury symptoms  of  pain  and  weakness 
in  the  lumbar  region,  increased  by 
sudden  motions  or  overexertion,  may 
be  persistent  and  disabling.  Such 
cases  are  often  classed  as  chronic  lum- 
bago, but  it  is  probable  that  there  is 
in  many  instances  a  distinct  injury 
of  the  ligaments  or  deep  muscles  of 
the  spine  or  strain  or  displacement  at 
the  sacroiliac  articulation,  aggra- 
vated, it  may  be  in  certain  cases,  by 
rheumatism  or  other  general  affection 
of  like  character. 

Ludloff^  has  called  attention  to  the 
fact  that  persistent  pain  about  the 
sacrum  following  falls  or  other  in- 
juries may  be  explained  in  many  in- 
stances by  a  slight  degree  of  trau- 
matic spondylolisthesis. 

Treatment. — The  treatment  must 
be   primarily   directed   to  the   condi- 
tion of  which  the  pain  is  a  sym]:»toni. 

If  motion  causes  pain  and  if  the  symptoms  are  persistent,  as 
in  the  lumbago  type  of  cases,  whether  due  to  injury  or  to  inflam- 
mation of  the  fibrous  or  muscular  tissues,  support  is  indicated, 
the   Knight   brace   or   plaster   corset   being   convenient   forms. 
'  Fortsch.  auf  d.  Gebiete  der  Eoentgenstrahlen,  Band  ix..  Heft  3. 


Spondylolisthesis  in  an  ado- 
lescent, induced  apparently  by 
overwork.  Symptoms  :  in- 
ability to  bend  forward  and 
pain  on  fatigue,  radiating 
down  back   of  the  thighs. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE.         145 

During  the  more  acute  stage  the  application  of  the  cautery  and 
the  support  of  intersecting  strips  of  adhesive  plaster,  covering 
a  wide  area,  even  encircling  the  pelvis,  will  often  relieve  the 
pain.     Later,  massage,  electricity,  and  the  like  are  of  service. 

In  milder  cases,  in  which  the  symptoms  may  be  dependent 
on  a  general  descent  of  the  abdominal  and  pelvic  organs,  an  ab- 
dominal belt  will  afford  great  relief. 

DEFORMITY  SECONDARY  TO  SCIATICA. 

Synonym. — Sciatic  scoliosis. 

Chronic  sciatica  often  induces  a  change  in  the  attitude  and 
contour  of  the  spine  that  may  become  a  permanent  deformity  if 
its  cause  persists.  As  a  rule,  the  patient  habitually  inclines  the 
body  away  from  the  painful  part  in  order  to  relieve  it  from 
weight,  bends  the  body  slightly  forward  and  abducts  the  limb 
to  relax  the  tension  on  the  sensitive  nerve  or  plexus  of  nerves. 
Thus,  the  pelvis  on  the  affected  side  projects,  there  is  a  lateral 
lumbar  convexity  toward  the  opposite  side,  and  often  the 
normal  lumbar  lordosis  is  lessened  or  lost,  so  that  the  final 
result  may  be  a  persistent  lateral  curvature,  together  with  a 
change  in  the  anteroposterior  contour  of  the  spine.  If  the  de- 
formity persists  a  second  compensatory  curve  may  appear 
(Fig.  88).  If  the  sciatica  is  a  symptom  of  a  more  widespread 
neuritis,  muscular  weakness  and  muscular  spasm  may  cause 
variations  in  the  typical  attitude,  the  muscles  of  one  side  being 
persistently  contracted. 

It  must  be  borne  in  mind  that  disease  of  the  lumbar  spine, 
particularly  at  the  lumbosacral  articulation,  or  injury  or  disease 
at  the  sacroiliac  junction,  may  induce  similar  distortion  of  the 
spine  accompanied  by  pain  in  the  limbs.  Also  that  disease  of 
the  pelvic  bones  or  of  the  adjacent  organs  or  parts,  may  set  up 
sciatica ;  thus,  the  cause  of  pain  should  be  carefully  sought  for. 

Aside  from  the  direct  treatment  of  sciatica,  support  for  the 
spine,  preferably  a  light  corset,  so  arranged  as  to  preserve  the 
lumbar  lordosis  and  to  exert  firm  pressure  about  the  pelvis,  may 
be  indicated  if  motion  aggravates  the  pain.  If  the  deformity 
persists  it  should  be  corrected  gradually,  by  repeated  applica- 
tions of  a  plaster  jacket. 

Neuritis  in  other  regions  of  the  spine  may  cause  symptoms  of 
reflected   pain   and  local   sensitiveness.      These   symptoms   are 
increased  by  motion,  and  a  certain  amount  of  local  deformity, 
similar  in  character  to  that  due  to  sciatica,  may  be  present. 
10 


146  ORTHOPEDIC  SURGEEY. 

Tlie  treatment  is  similar  to  that  indicated  in  the  former 
affection. 

SACROILIAC  DISEASE. 

Tuberculous  disease  of  the  sacroiliac  articulation  as  compared 
to  disease  of  the  spine  or  hip  joint  is  a  rare  affection  and  ex- 
tremely so  in  childhood. 

Sjnnptoms. — The  symptoms  are  pain,  weakness,  limp,  and 
change  in  attitude.  The  pain  is  referred  to  the  side  of  the 
pelvis  or  radiates  over  the  buttock  or  thigh.  It  is  increased  by 
jars,  by  turning  the  body  suddenly,  sometimes  by  coughing  or 
laughing;  and  a  peculiar  feeling  of  insecurity  and  weakness  is 
sometimes  complained  of.  As  a  rule,  the  body  is  inclined 
toward  the  sound  limb ;  thus  the  pelvis  is  lowered  on  the  affected 
side  and  the  leg  seems  longer  than  its  fellow.  In  the  early  stage 
of  the  disease  there  is  no  deformity  of  the  limb,  but  if  a  pelvic 
abscess  forms,  the  thigh  may  become  flexed.  Locally,  there  may 
be  sensitiveness  to  pressure  over  the  articulation,  or  from  within 
by  rectal  examination,  and  swelling  in  the  neighborhood  of  the 
disease,  although  this  is  usually  a  late  symptom.  Pain  is  in- 
duced by  forward  bending  of  the  body  or  by  flexing  the  extended 
limb  on  the  trunk,  movements  that  make  the  hamstring  muscles 
tense,  by  lateral  pressure  on  the  pelvis  or  by  other  manipula- 
tion that  moves  the  articulation. 

Abscess  flnally  forms  in  the  majority  of  cases.  It  may  be 
extrapelvic  or  intrapelvic.  The  intrapelvic  abscess  may  present 
above  the  crest  of  the  ilium,  or  the  pus  may  pass  through  the 
sciatic  notch,  or  appear  in  the  ischiorectal  fossa,  or  break  into 
the  rectum. 

Diagnosis. — Sacroiliac  disease  may  be  mistaken  for  sciatica 
or  for  disease  of  the  Jiij^  or  spine.  The  freedom  of  motion  and 
the  absence  of  muscular  spasm  when  the  pelvis  is  fixed,  if  the 
examination  is  carefully  conducted,  should  exclude  the  former. 
And  although  the  movements  of  the  spine  may  be  checked  by 
muscular  spasm  it  is  not  in  the  same  degree  as  when  the  verte- 
bras are  diseased.  The  pain  on  lateral  pressure,  which  is  de- 
scribed as  the  most  characteristic  symptom,  may  sometimes  be 
simulated  closely  by  primary  acetabular  disease.  The  attitude 
is  similar  to  that  of  sciatica,  but  the  symptoms  of  local  sensi- 
tiveness to  jars  and  to  manipulation  are  much  more  marked. 

Prognosis. — According  to  the  statistics  the  prognosis  is  very 
unfavorable,    probably   because    the   majority   of   the    reported 


NON-TUBEBCULOUS  AFFECTIONS  OF  THE  SPINE.         147 


cases  were  in  adults  complicated  by  coincident  disease  of  the 
lungs  and  by  infected  and  burrowing  abscesses,  which  consti- 
tute the  chief  danger  of  this  form  of  tuberculous  disease. 


Fig. 


Fig.  89. 


Deformity  caused  by  persistent  sci- 
atica of  the  right  side.  This  attitude 
is  similar  to  that  symptomatic  of  sacro- 
iliac disease. 


Sacroiliac  disease  in  a  child, 
showing  the  extra  pelvic  abscess 
above   the   diseased   articulation. 


Treatment.- — The  local  treatment  consists  in  protecting  the 
diseased  parts  from  injury.  This  in  painful  cases  requires 
complete  rest  of  the  individual.  Local  support  may  be  assured 
by  a  double  Thomas  hip  splint  or  spica  plaster  including  the 


148  ORTHOPEDIC  SUBGEBY. 

body  and  both  limbs.  In  milder  cases  a  back  brace  with  a  wide 
pelvic  band  so  arranged  that  firm  pressure  may  be  made  about 
the  pelvis  supplemented  by  crutches  may  permit  ambulation. 

When  infected  abscess  is  present  radical  treatment  is  usually 
indicated.  The  articulation  should  be  freely  exposed  and  the 
diseased  bone  should  be  entirely  removed,  if  possible.  Intra- 
pelvic  abscess  should  be  drained  through  a  direct  communica- 
tion, if  possible,  in  order  to  check  the  tendency  toward  bur- 
rowing. 

The  sacroiliac  articulation  being  a  true  joint  may  be  involved 
in  other  forms  of  disease,  for  example  in  arthritis  deformans. 

INJURY  OF  THE  SACROILIAC  ARTICULATION. 

The  symptoms  of  sacroiliac  disease  that  have  been  described 
may  be  caused  by  falls  on  the  buttock  or  pelvis  or  by  strains. 
In  such  cases  there  may  be  an  actual  injury  or  displacement  at 
the  articulation.  This  condition  was  carefully  described  by 
Lee  in  1893,^  and  it  is  now  recognized  as  of  comparatively  fre- 
quent occurrence. 

Goldthwait^  han  called  particular  attention  to  relaxation  of 
the  pelvic  articulations  caused  by  malposition  of  the  sacrum — 
which  rotating  from  its  normal  forward  inclination  to  a  more 
perpendicular  attitude  no  longer  serves  its  proper  function  as  a 
wedge  to  hold  the  pelvic  ligaments  in  proper  tension.  This 
condition  is  favored  by  pregnancy,  by  long  confinement  to  bed 
for  illness  or  other  cause,  when  the  lumbar  region  being  unsup- 
ported loses  its  forward  inclination  and  the  sacroiliac  articula- 
tions are  relaxed.  Thus  it  may  be  assumed  that  a  lessening  of 
the  lurobar  lordosis  is  not  only  a  direct  cause  of  discomfort  but 
that  iit  predisposes  to  weakness  of  the  sacroiliac  articulation. 
Uii.der  favoring  conditions  even  slight  injury  may  be  followed 
by  disabling  symptoms  of  the  character  described.  It  may  be 
noted  that  chronic  "lumbago,"  sciatica  and  injury  or  disease 
of  this  articulation  present  similar  symptoms  and  fortunately 
all  may  be  treated  in  a  like  manner,  the  essentials  being  to  restore 
the  normal  lordosis  and  to  restrain  all  movements  that  cause 
pain.  This  may  require  rest  in  bed  or  even  the  administration 
of  an  anaesthetic  for  the  purpose  of  correcting  long  standing 
deformity,  the  application  of  fixed  plaster  supports  and  the  like 
in  the  treatment  of  severe  cases,  while  in  the  mild  type  posture 
and  exercises  may  suffice. 

^  Trans.  Amer.  Orthop.  Assn.,  vol.  ii. 
^Bull.  Medicale,  June  15,  1901. 


CHAPTER  III. 

LATERAL   CURVATURE   OF   THE   §PINE. 

Synonyms. — Eotary  lateral  curvatiire;  scoliosis. 

Definition  and  General  Description.^ — Lateral  curvature  of 
the  spine  is  an  habitual  or  fixed  deformity  in  which  the  spine 
is  inclined  in  whole  or  part  to  one  or  the  other  side  of  the 
median  line. 

By  limiting  the  term  to  habitual  deformity  one  excludes 
simple  postural  inclination  of  the  spine.  For  example,  if  one 
leg  were  considerably  shorter  than  the  other  the  pelvis  would  be 
tilted  downward  on  the  short  side,  and  there  would  be  a  com- 
pensatory curvature  of  the  spine  in  the  erect  attitude,  which 
would  disappear  in  the  sitting  posture.  This  accommodative 
or  compensatory  inclination,  and  those  of  similar  origin,  are 
not,  in  the  proper  sense,  lateral  curvatures. 

In  persistent  lateral  curvature  the  anterior  part  of  the  column 
is  more  distorted  than  are  the  spinous  processes,  because  lateral 
bending  is  always  accompanied  by  rotation  of  the  vertebral 
bodies  toward  the  convexity  of  the  curve,  the  spinous  processes 
turning  in  the  reverse  direction.  Thus  well-marked  rotation 
may  be  present,  with  but  slight  lateral  deviation  of  the  spinousi 
processes. 

In  the  physiological  movements  of  the  spine,  direct  lateral 
movement — that  is,  movement,  permitted  by  the  small  i(  ints  of 
the  spine  and  by  the  lateral  compression  of  the  intervei  :ebral 
disks — is  very  limited.  The  larger  movements  must  be  acc*-m- 
panied  by  rotation  of  the  vertebral  bodies  by  which  this  continu- 
ous or  solid  part  of  the  column  is,  as  it  were,  forced  from  th^ 
shortened  toward  the  lengthened  side  (Tig.  90).  If,  for  ex- 
ample, one  attempts  to  place  the  ear  as  near  the  shoulder  as  is 
possible  there  is  necessarily  an  accompanying  rotation  of  the 
chin  in  the  opposite  direction  caused  by  the  twisting  of  the 
bodies  of  the  cervical  vertebrse  toward  the  convexity  of  the  curve. 

In  the  simple  accommodative  lateral  inclination  of  the  body 
to  one  side  or  the  other,  the  change  in  contour  of  the  spine  would 
be  more  noticeable  if  it  could  be  observed  from  the  front  rather 
than  from  the  back,  and  as  lateral  curvature  is  simply  a  per- 

149 


150 


OETEOPEDIC  SUEGEBY. 


sistent  deviation  of  the  spine,  one  of  the  so-called  static  deformi- 
ties which  are  directly  induced  or  exaggerated  by  superincum- 
bent weight,  it  may  be  assumed  that  rotation  of  the  vertebral 
bodies  precedes  the  lateral  distortion  that  first  attracts  attention. 
Slight  rotation  may  not  cause  at  once  an  appreciable  degree 
of  external  distortion,  and,  although  marked  lateral  curvature 

Fig.  90. 


Physiological  rotation  accompanying  flexion  and  lateral   inclination  of  the  trunk 
in  the  normal  subject. 


^is  necessarily  combined  with  rotation,  yet  a  slight  degree  of 
direct  lateral  inclination  may  exist  unaccompanied  by  appre- 
ciable rotation.  Rotation  is  usually  understood  to  imply  fixed 
deformity,  while  lateral  deviation  may  mean  simply  an  habitual 
posture ;  but  it  is  far  simpler  to  consider  the  two  as  parts  of  one 
distortion.  The  important  distinction  is  between  habitual  de- 
formity, implying  the  habitual  assumption  of  an  improper  atti- 
tude in  which  the  accommodative  changes  in  structure  have  not 
advanced  suiliciently  to  prevent  voluntary  or  passive  correction, 
and  fixed  deformity  in  which  the  changes  in  the  bones  and  other 


LATERAL  CUEVATUBE  OF  THE  SPINE.  151 

tissues  have  made  cure  difficult  or  impossible.  The  evidence  of 
fixed  deformity  is  rotation  that  persists  after  the  lateral  devia- 
tion has  been  overcome.  It  persists  because  the  early  and  im- 
portant changes  must  take  place  in  the  bodies  of  the  vertebrae 
upon  which  the  weight  falls,  but  there  is  no  reason  to  believe 
that  habitual  rotation  as  an  accompaniment  of  habitual  lateral 
curvature  may  not  be  corrected  if  it  be  treated  at  the  proper 
time. 

The  distribution  of  the  weight  about  the  centre  of  gravity  in 
balancing  the  body  in  the  upright  position  explains  the  charac- 
teristics of  lateral  curvature.  As  the  normal  contour  of  the 
spine  is  the  result  of  static  conditions,  a  change  from  this 
normal  relation  of  one  part  induces  a  corresponding  change 
elsewhere.  If  there  is  a  primary  lumbar  curvature  and  rota- 
tion to  the  left  in  the  lower  region,  a  corresponding  lateral 
deviation  and  rotation  to  the  right  in  the  region  above  usually 
develops,  thus  restoring  the  balance  of  the  body.  This  explains 
the  ordinary  S-shaped  or  double  curve  of  scoliosis,  one  of  which 
is  primary  and  the  other  secondary.  These  curves  may  divide 
the  spine  equally  or  one  may  be  long  and  the  other  short  and 
occasionally  three  distinct  curves  may  be  present.  If  the  pri- 
mary curve  is  slight,  the  secondary  curvature  will  be  slight  also, 
and  the  primary  curve  persists  doubtless  for  a  time  before  com- 
pensation appears.  In  some  instances  the  spine  may  be  bent 
laterally  into  one  long  curve,  "total  scoliosis  "  (Fig.  91).  This 
is,  in  many  instances,  the  initial  stage  of  the  ordinary  type  of 
scoliosis,  the  long  curve  being  afterward  divided.  In  child- 
hood total  scoliosis  is  often  combined  with  general  posterior 
curvature,  and  it  is  peculiar  in  that  the  torsion  of  the  vertebrfe 
may  be  toward  the  concave  instead  of  the  convex  side,  the  tor- 
sion representing  probably  the  early  stages  of  the  secondary  or 
compensatory  curve. 

It  has  been  stated  that  deformity  of  one  part  of  the  spine  is 
usually  balanced  by  deformity  of  another.  This  enables  the 
trunk  to  hold  the  erect  posture,  and  it  restores  its  general  sym- 
metry. If,  however,  a  long  lateral  or  long  posterior  curvature 
persists,  the  weight  can  be  balanced  only  by  swaying  the  entire 
body  on  the  pelvis,  in  the  direction  opposed  to  the  distortion. 
This  restores  the  balance,  but  not  the  symmetry  (Fig.  105). 

Rotation  and  Lateral  Deviation. — Fixed  rotation  of  the  spine 
carries  with  it,  of  course,  all  the  parts  that  are  attached  to  it. 
When  the  patient  stands  in  the  erect  attitude  the  simple  lateral 


152 


OBTEOPEDIC  SUBGEBY. 

Fig.  91. 


CongeBital  total  scoliosis.     Compared  with  Fig.   92. 
Fig.  92. 


Congenital   total   scoliosis.     The  rotation  is  much  greater  than   the  lateral   devi- 
ation.    Compare  with   Fig.   91. 


LATERAL  CUBFATUBE  OF  TEE  SPINE. 


153 


distortion  is  most  noticeable  (Fig.  91),  but  when  the  body  is 
bent  forward  tbe  twist  of  the  trunk  becomes  the  prominent  de- 
formity (Fig.  92).  If  the  thoracic  region  is  involved,  the  ribs 
on  the  side  toward  which  the  spine  is  rotated  project  backward, 


Fig.  93. 


Primary  lumbar  curvature  to  the  left.     A  "  flat  back  "  marked  rotation  with  but 
slight  lateral  curvature. 

and  on  the  other  side  of  the  spine  there  is  a  corresponding  flat- 
ness or  depression.  The  projection  of  the  ribs  due  to  the  dis- 
tortion of  the  thorax  is  far  more  noticeable  Ihan  is  the  simple 
twisting  of  the  free  portions  of  the  spine  in  the  neck  or  loins ; 
and  in  these  regions  the  projecting  transverse  processes  covered 
by  the  thick  layers  of  muscles,  yet  unaccompanied  by  marked 
lateral   deviation,   may   cause   mistakes   in   diagnosis.      In  the 


154 


OBTHOPEDIC  SUEGEBY. 


cervical  region,  for  example,  as  an  accompaniment  of  acute  tor- 
ticollis, the  projection  may  be  mistaken  for  abscess ;  and  in  the 
lumbar  region  it  has  been  mistaken  for  a  new-growth  attached 
to  the  spine. 

Although  persistent  lateral  curvature  of  the  spine  is  always 
accompanied  by  rotation,  the  degree  of  rotation  does  not  always 
correspond  to  that  of  the  more  evident  lateral  deviation.     In  the 

Fig.  94. 


Scoliosis  with  marked  posterior  deformity. 


instance  cited,  rotation  in  the  lumbar  region,  so  extreme  as  to 
simulate  an  abnormal  growth,  maj  be  present  with  but  slight 
lateral  distortion;  while  in  other  instances  the  body  appears  to 
be  greatly  displaced  to  one  side,  although  there  may  be  compara- 
tively little  fixed  rotation.  Again,  as  has  been  stated,  the  lateral 
deviation  of  the  trunk  is  usually  more  noticeable  than  the  rota- 
tion, which  in  the  slighter  grades  of  deformity  is  only  made 
apparent  when  the  patient  is  bent  forward  so  that  the  back  may 


LATEBAL  CUEVATUBE  OF  THE  SPINE.  155 

be  inspected  in  the  horizontal  position.  It  may  be  noted,  also, 
that  the  degree  of  habitual  lateral  distortion  of  the  body  does 
not  correspond  to  the  degree  of  fixed  distortion.  One  individual, 
by  voluntary  effort,  may  practically  conceal  advanced  deformity, 
while  another  who  makes  no  effort  to  correct  the  improper  pos- 
ture appears  to  be  greatly  distorted,  although  the  fixed  changes 
may  be  very  slight. 

The  effects  of  the  deformity,  both  general  and  local,  depend 
upon  its  situation  and  its  degree.  In  one  instance  it  may  be  so 
slight  as  to  pass  unnoticed,  and  in  another  the  distortion  may 
eqiTal  that  of  Pott's  disease  (Fig.  94).  If  compensation  is  per- 
fect— that  is,  if  the  deformity  is  equally  distributed  on  either 
side  of  the  median  line — the  general  symmetry  of  the  body  may 
be  but  slightly  disturbed.  Or,  if  the  compensation  for  the  pri- 
mary deformity  of  the  lumbar  region  is  distributed  throughout 
the  remainder  of  the  spine,  noticeable  distortion  may  be  insig- 
nificant, but  when  there  is  a  long  curve  involving  the  thoracic 
region  the  lateral  and  posterior  displacement  cannot  be  con- 
cealed (Fig.  95). 

Changes  in  the  Anteroposterior  Contour.- — Lateral  distortion  in- 
volves also  secondary  changes  in  the  anteroposterior  outline  of 
the  spine.  If  the  distortion  is  marked  the  stature  is  shortened, 
especially  when  the  anteroposterior  curves  are  increased.  In 
general,  one  may  recognize  two  types  of  lateral  curvature :  one 
in  which  the  back  is  flatter  than  normal,  in  which  the  antero- 
posterior curves  are  diminished,  and  another  in  which  they 
are  increased.  It  has  been  stated  in  the  account  of  Pott's 
disease  that  deformity  in  one  segment  of  the  spine  always 
caused  a  change  in  the  contour  of  the  spine  as  a  whole,  that 
an  obliteration  or  a  lessening  of  the  concavity  of  the  lumbar 
region  was  accompanied  by  a  corresponding  flattening  of  the 
normal  dorsal  kyphosis.  On  the  other  hand,  that  an  increase 
in  the  backward  projection  of  the  dorsal  region  caused  an 
increased  concavity  below.  The  variations  in  the  anteropos- 
terior contour  of  the  spine  in  lateral  curvature  may  be  ac- 
counted for  in  the  same  manner.  In  the  one  instance  the 
primary  deformity  is  of  the  lower  region,  and  with  its  accom- 
panying backward  twist  of  the  vertebral  bodies  it  lessens  the 
lumbar  lordosis  and  tends  to  flatten  the  back  (Fig.  93).  If,  on 
the  other  hand,  the  deformity  begins  in  the  thoracic  region,  the 
primary  effect  is  to  increase  the  backward  projection,  and  this 
in  turn  tends  to  exaggerate   the  lumbar  lordosis    (Fig.    94  L 


156 


ORTHOPEDIC  SURGEEY. 


Thus,  the  shortening  of  the  trunk  in  the  lumbar  region  caused 
by  the  lateral  deviation  may  be  to  a  certain  extent  compensated 
in  the  first  instance,  while  in  the  other  both  the  primary  and 
secondary  distortions  tend  to  reduce  the  height. 

The  "  High  "  Shoulder  and  the  "  High  "  Hip. — If  the  convex- 
ity of  the  primary  curve  is,  for  example,  to  the  left  in  the  lum- 
bar region  the  trunk  is  displaced  somewhat  to  the  left,  conse- 

FiG.  95. 


Scoliosis  with  extreme  lateral  deviation. 


quently  the  right  pelvic  crest  becomes  abnormally  prominent,  a 
prominence  that  is  usually  mistaken  for  an  elevation,  and  in 
compensation  there  is  a  corresponding  twist  in  the  opposite  direc- 
tion above.  The  spine  bending,  and  at  the  same  time  rotating 
toward  the  right,  carrying  with  it  the  ribs,  raises  the  shoulder 
and  makes  the  scapula  prominent.  Thus  it  is  that  in  the 
ordinary  S-shaped  cur^'e  the  high  shoulder  and  the  prominent 


LATERAL  CUBVATUBE  OF  THE  SPINE.  157 

hip  appear  usually  upon  the  same  side  of  the  body.  But  in  less 
regular  varieties  of  distortion,  when,  for  example,  there  is 
marked  general  lateral  deviation  of  the  trunk  as  a  whole,  the 
high  shoulder  may  be  on  the  opposite  side  (Fig.  102).  It  is 
probable  that  the  primary  curvature  is  in  most  instances  to  the 
left  in  the  lumbar  region,  the  compensation  to  the  right  appear- 
ing at  a  later  time.  This  is  certainly  true  of  the  milder  types 
of  postural  curvature. 

Pathology. — Lateral  curvature  of  the  spine  is  a  deformity, 
not  a  disease,  nor  is  it  ordinarily  an  effect  of  disease.  For  this 
reason  the  description  of  the  pathology  which  is  merely  a  more 
detailed  account  of  the  deformity  and  of  its  secondary  effects 
upon  the  trunk  and  its  contents  may,  for  convenience,  precede 
the  discussion  of  the  etiology. 

In  such  a  description  one  must  consider  the  trunk  as  a  whole, 
its  central  column  bent  and  twisted,  in  which  each  component 
segment  shares  in  the  general  distortion.  The  vertebra  at  the 
apex  of  each  curve  shows  the  greatest  change.  If  the  rotation 
and  lateral  deviation  is  to  the  right  the  vertebral  body  is  some- 
what wedge-shaped,  the  apex  of  the  wedge  being  directed  back- 
ward and  to  the  left.  Its  lateral  diameter  is  increased  and  the 
superior  and  inferior  margins  at  the  narrow  side  project,  in- 
creasing its  lateral  concavity  (Fig.  99).  Similar  accommo- 
dative changes,  although  less  marked,  are  to  be  found  in  the 
articular  processes  and  in  the  laminae;  in  fact,  all  the  parts  on 
the  concave  side  are  broadened,  shortened,  and  lessened  in 
vertical  diameter  as  compared  with  those  on  the  convex  side  of 
the  spine.  These  changes  affect  the  shape  of  the  neural  canal, 
which  becomes  somewhat  ovoid  in  outline,  the  base  being- directed 
toward  the  convexity  of  the  curve  (Fig.  100).  In  the  vertebrse, 
included  in  the  compensatory  curvature,  the  deformities  are 
reversed,  and  the  intermediate  segments  show  the  transitional 
changes  between  the  two  extremes.  The  intervertebral  disks 
become  wedge-shaped  also,  and  atrophied  on  the  shortened  side, 
the  changes  in  these  softer  tissues  preceding,  undoubtedly,  those 
in  the  bones.  The  articulations  of  the  vertebrae  become  changed 
in  shape  and  position  in  the  general  adaptation  to  the  deformity 
and  the  ligaments  are  shortened  or  lengthened  according  to  their 
relation  to  the  distortion. 

On  section  the  internal  structure  of  the  vertebrae  shows  the 
same  adaptive  changes  that  are  evident  on  the  exterior.  In  the 
narrowed  parts  of  the  bones  that  bear  the  weight  the  tissue  is 


158 


OBTEOPEDIC  SUBGEBY. 


^ 


thick  and  compact,  on  the  opposite  side  it  is  attenuated  and 
atrophied. 

The  mobility  of  the  spine  is  lessened  by  these  changes  in  its 
shape  and  structure,  primarily  by  the  distortion,  secondarily  by 


')l0i^* 


> 


the  shortening  of  the  tissues  on  the  concave  side,  by  the  irregu- 
larities of  the  vertebral  bodies,  by  the  interference  of  the  newly 
formed  or  transformed  bone  which  is  thrown  out  about  the 
margins  of  the  vertebrse  and  the  articular  processes,   and  by 


LATERAL  CUBVATUEE  OF  THE  SPINE. 


159 


ossification  of  the  periosteum  and  ligamentous  coverings  of  the 
adjacent  bones.  Thus,  in  fixed  deformity  there  may  be,  at  the 
points  of  greatest  distortion,  practical  anchylosis.  The  muscles 
of  the  back,  both  intrinsic  and  extrinsic,  undergo  adaptative 
changes,  and,  as  a  rule,  they  are  relatively  weak. 

The  most  important  of  the  secondary  deformities  of  lateral 
curvature  is  that  of  the  thorax.     This  is  somewhat  difficult  to 


Scoliotic  vertebrae.      (Hoffa.) 


describe,  because  the  distortion  of  the  dorsal  vertebrae  does  not 
affect  the  thorax  equally ;  thus,  it  is  not  twisted  as  a  whole,  nor 
flexed  as  a  whole.  The  nature  of  the  deformity  may  be  better 
understood  by  considering  the  sternum  as  a  fixed  point;  this, 
as  a  matter  of  fact,  it  is,  as  compared  with  the  spine.  At  the 
apex  of  the  convexity  of  the  curve  the  ribs  are  drawn  sharply 
backward;  their  angles  project  by  the  side  of  and  beyond  the 
spinous  processes,  sometimes  covering  and  concealing  them,  and 
the  lateral  convexity  of  the  chest  is  diminished  or  lost.  On  the 
opposite  side  the  back  is  broadened  and  flattened.  The  effect 
of  the  rotation  is  to  diminish  the  capacity  of  the  chest  on  the 


160 


ORTHOPEDIC  SUEGEBY. 


convex  side  and  to  increase  that  of  the  concave  side  (Fig.  101). 
On  the  convex  side  the  ribs  are  elevated  and  their  inclination 
is  increased.  On  the  concave  side  the  intercostal  spaces  are 
narrowed  and  the  inclination  is  lessened  (Fig.  97).  The  antero- 
posterior diameter  of  the  chest  is  increased  or  diminished  ac- 
cording to  the  change  in  the  anteroposterior  contour  of  the 
spine.  If  the  dorsal  kyphosis  is  exaggerated  the  effect  is  to 
deepen  the  chest  (Fig.  94)  ;  if  it  is  diminished,  the  diametey  of 
the  thorax  is  correspondingly  lessened. 

The  cervical  section  of  the  spine  is  not  often  involved, 
marked  degree  at  least,  in  the  lateral  deformity.     But  in  \ex- 


FiG.  100. 


Change  in  shape  of  the  spinal  canal,  broader  on  the  convex  side.      (HofEa.) 

treme  cases,  in  which  the  neck  and  head  are  habitually  distorted, 
there  may  be  accommodative  changes  in  the  skull  similar  to 
those  induced  by  persistent  torticollis. 

At  the  other  extremity  of  the  spiue  the  pelvis  is  not,  as  a  rule, 
markedly  deformed.  In  some  instances  the  oblique  diameter, 
opposed  to  the  convexity  of  the  lumbar  deformity,  may  be  in- 
creased, and  if  the  lateral  deviation  of  the  lumbar  spine  is 
extreme  the  pelvis  may  be  so  tilted  that  the  limb  on  the  elevated 
side  becomes  apparently  shorter  than  its  fellow. 

In  changes  that  have  been  described  the  contents  of  the  trunk 


LATEBAL  CURVATURE  OF  THE  SPINE. 


161 


participate  to  a  greater  or  less  degree.  The  lung  on  the  convex 
side  is  compressed  by  the  distorted  ribs  and  by  the  displaced 
vertebral  bodies.  The  heart  may  be  displaced  laterally  or  in 
other  directions  according  to  the  character  of  the  deformity, 
and  the  bloodvessels  are  changed  in  direction,  and,  it  may  be, 
altered  in  calibre.  In  those  cases  in  which  the  thorax  is  mark- 
edly distorted  the  effect  is  similar  to  that  of  the  deformity  of 
Pott's  disease ;  respiration  is  shallow  and  rapid,  the  pulse-rate 
is  usually  increased,  and  other  evidences  of  interference  with 
the  vital  functions  may  be  apparent.  The  abdominal  organs  are 
affected,  doubtless,  in  a  similar  manner,  but  symptoms  due  to 
this  cause  are  not,  as  a  rule,  as  clearly  marked. 

Fig.  101. 


Deformity   of   the   thorax   in   scoliosis.      (Hoffa.) 


Bachmann^  investigated  the  secondary  changes  induced  by 
severe  scoliotic  deformity  coming  under  his  observation  in  the 
pathological  institute  of  Breslau.  In  91.3  per  cent,  of  the  sub- 
jects defect  or  disease  of  the  circulatory  apparatus,  and  in  99.1 
per  cent,  of  the  respiratory  organs  was  observed. 

Etiology — Relative  Frequency. — Lateral  curvature  of  the 
spine  is  one  of  the  most  common  of  deformities.  In  a  period 
of  years  3252  cases  were  recorded  in  the  out-patient  dej)art- 
ment  of  the  Hospital  for  Euptured  and  Crippled,  a  number 

^  Bachmann,    Die    Veranderungen    an    den    inneren    Organen    bei    hoch- 
gradigen  Skoliosen  und  Kyphoskoliosen,  Bibliotheca  Medica,   1900,   Ab.  D. 
1,  H.  4. 
11 


162  OETHOPEDIC  SUEGEEY. 

only  exceeded  by  that  of  bow-legs,  of  which  5030  cases  were 
treated. 

The  relative  frequency  of  lateral  curvature  araong  children 
in  general  is  illustrated  by  the  statistics  of  Drachmann.  who 
found  among  28,175  school-children  (16,789  boys,  11,386  girls) 
of  Denmark  368  cases  of  scoliosis  (1.3  per  cent.),  and  those  of 
Scholder,  "Werth,  and  Combe,^  who  found  571  cases  of  lateral 
curvature  among  2314  school-children  of  Switzerland  (24.6 
per  cent.),  a  discrepancy  that  is  somewhat  difficult  to  explain. 

Sex. — Lateral  curvature  of  the  spine  is  far  more  common 
among  females  than  males.  Of  the  3252  cases  referred  to,  2554 
(78.5  per  cent.)  were  in  females  and  698  (21.4  per  cent.)  were 
in  males. 

The  lowest  percentage  of  males  in  any  one  of  the  fifteen  years 
was  14.8,  the  highest  25.1.  This  proportion  of  one  male  to  four 
females  is  somewhat  larger  than  in  the  smaller  groups  of  cases 
reported  by  other  observers. 

The  unequal  distribution  of  the  deformity  between  the  sexes 
is  of  great  interest  as  bearing  on  the  question  of  etiology;  espe- 
cially so  as  in  the  cases  that  develop  in  early  childhood,  sex  ap- 
pears to  exercise  practically  no  influence.  It  has  been  suggested 
that  curvature  of  the  spine  in  a  girl  is  looked  upon  with  more 
solicitude  by  the  mother  than  is  the  same  deformity  in  a  boy, 
therefore,  more  girls  are  brought  for  treatment.  There  may  be 
some  basis  for  this  argument,  for  it  is  certain  that  distortions 
of  the  lower  extremities  are  considered  of  greater  importance  in 
male  than  in  female  children,  because  of  the  concealment  to  be 
afforded  by  the  skirts,  if  the  deformity  is  not  outgrown.  But 
gTanting  that  statistics  are  somewhat  unreliable,  there  can  be 
no  doubt  but  that  this  deformity  is  far  more  common  among 
girls  than  boys  and  that  the  disiDroportion  may  be  explained,  in 
great  part  at  least,  by  the  differences  in  dress  and  in  manner  of 
life. 

Age.. — One  thousand  two  hundred  and  ninety-nine  (39.9  per 
cent.)  of  the  3252  patients  referred  to  were  less  than  fourteen 
years  of  age.;  1576  (48.4  per  cent.)  were  between  fourteen  and 
twenty-one;  377  (11.6  per  cent.)  were  more  than  twenty-one 
years  of  age.  These  statistics  simply  show  the  age  of  the  pa- 
tients at  the  time  treatment  was  sought,  and  they  are  of  little 
value  as  an  indication  of  the  age  at  which  deformity  might  have 
been  detected  had  it  been  looked  for. 

'  Extrait   cles  Annals   Suisses   d 'Hygiene   Scolaire,   1901. 


LATEEAL  CUBVATUEE  OF  TEE  SPINE.  163 

There  is  no  reason  to  suppose  that  lateral  curvature  of  the 
spine  differs  in  its  etiology  from  similar  deformities  of  other 
parts,  except  in  so  far  as  each  region  of  the  body  is  more  or 
less  susceptible  to  deforming  influences  at  one  time  than  another. 

For  example,  rhachitic  deformities  of  the  upper  extremities 
practically  never  develop  except  in  infancy,  and  they  begin  to 
correct  themselves  when  the  erect  j)osture  is  assumed  or  at  the 
very  time  when  distortions  of  similar  origin  of  the  lower  ex- 
tremities appear  or  increase.  When  deformities  of  this  class, 
whether  of  the  spine  or  limbs,  appear  in  later  childhood  or 
adolescence  it  may  be  assumed  that,  in  many  instances  at  least, 
the  tendency  toward  the  particular  deformity,  or  even  a  slight 
degree  of  deformity,  was  acquired  at  an  early  age,  that  it  re- 
mained latent  until  conditions  appeared  which  favored  its 
further  development.  This  point  is  illustrated  by  the  statistics 
of  Eulenburg  of  1000  cases  of  lateral  curvature  analyzed  with 
reference  to  the  inception  of  the  deformity. 

Between  birth  and  the   sixth  year 78 

Between  the  sixth  and  seventh  years 216 

Between  the  seventh  and  tenth  years 564 

Between  the  tenth  and  fourteenth  years 107 

After  the  fourteenth  year 35 

1000 

It  will  be  noted  that  but  142  (14.2  per  cent.)  of  these  patients 
were  more  than  fourteen  years  of  age  as  contrasted  with  the 
statistics  of  the  Hospital  for  Euptured  and  Crippled,  in  which 
60  per  cent,  were  beyond  this  age. 

Dr.  Walter  Truslow,  who  for  several  j'^ears  had  the  immediate 
charge  of  the  treatment  of  lateral  curvature  at  the  Hospital  for 
Ruptured  and  Crippled,  prepared  for  me  statistics  of  a  number 
of  the  cases  which  illustrate  the  same  point. 

But  44  of  the  181  patients  (22.6  per  cent.)  were  more  than 
thirteen  years  of  age  at  the  time  when  the  deformity  was  first 
noticed,  although  nearly  50  per  cent,  were  older  than  this  when 
treatment  was  applied  for.  In  the  first  table  it  will  be  noted 
that  of  the  38  patients  who  were  ten  years  of  age  or  less,  15,  or 
about  40  per  cent.,  were  males.  Of  25  of  the  37  cases  in  which 
the  deformity  attracted  attention  at  or  before  the  sixth  year 
rhachitis  was  the  apparent  cause. 

Lateral  curvature  of  the  spine  is  one  of  the  penalties  of  the 
erect  posture,  and  the  force  of  gravity  must  be  considered  both 
as  a  predisposing  and  as  an  exciting  cause  of  the  deformity. 


164 


ORTHOPEDIC  SUBGEBY. 


A. — Age  when  Treatment  was  Begun, 

Age  when  Examined.                                                      Males.  Females. 

4  years 0  1 

5  years 0  1 

6  years 1  1 

7  years 4  2 

8  years 4  7 

9  years 4  4 

10  years 2  7 

11  years 3  13 

12  years 3  16 

13  years 4  28 

14  years 5  25 

15  years  3  21 

16  years 8  14 

17  years 2  6 

18  years 1  2 

19  years 0  1 

20  years 0  1 

21  years 0  4 

23  years 0  1 

24  years 0  1 

32  years 0  1 

44  157 

B. — Age  when  the  Deformity  was  Discovered, 

Males. 

Congenital  (sex  not  stated) 2 

During  infancy  (sex  not  stated) 19    ' 

Between     3  and     6  years 16             10 

Between     6  and  10  years 41             10 

Between  10  and  13  years 62               6 

Between  13  and  15  years 27               3 

Over         15  years 14               3 

Unknown    20 

201  32 


Females. 


6 
31 
56 
24 
11 

128 


The  more  direct  tendency  of  the  force  of  gravity  is  to  cause  the 
body  to  sink  forward  and  to  increase  the  posterior  curvature  of 
the  spine,  but  whenever  there  is  a  persistent  inclination  of  the 
spine  to  one  or  the  other  side  this  inclination  is  likely  to  be  in- 
creased to  deformity  under  favoring  conditions.  These  favoring 
conditions  would  include  general  weakness  from  any  cause ; 
overwork  that  may  induce  fatigue,  and  all  factors,  mechanical 
or  otherwise,  that  may  add  to  the  difficulty  of  holding  the  trunk 
erect  under  the  pressure  of  the  superincumbent  weight. 

Predisposing  Causes Although  it  is  not  difficult  to  suggest 

the  predisposing  causes  of  lateral  curvature,  it  is  by  no  means  as 
easy  to  point  out  the  direct  cause  of  the  original  inclination  of 
the  spine  to  one  or  the  other  side  of  the  median  line.  In  a  cer- 
tain number  of  cases,  however,  the  relation  between  cause  and 
effect  is  sufficiently  evident,  and  these  causes  may  be  enumer- 
ated before  considering  the  larger  class  in  which  the  etiology  is 
more  obscure. 


LATEBAL  CUEVATUBE  OF  TEE  SPINE.  165 

1.  Lateral  curvature  secondary  to  deformity  of  other  parts. 

2.  Static  or  compensatory  deformity. 

3.  Deformity  secondary  to  disease  of  the  nervous  system. 

4.  Deformity  secondary  to  disease  of  the  thoracic  organs. 

5.  Incidental  deformity. 

6.  Deformity  due  to  occupation. 

7.  Congenital  deformity. 

8.  Rhachitic  deformity. 

1.  Lateral  Cuevatuke  Secondaky  to  Deformity  Else- 
where.—  (a)  Lateral  curvature  of  the  spine  may  be  a  compen- 
satory effect  of  torticollis,  either  congenital  or  acquired,  (b) 
It  may  be  induced  by  distortion  of  the  lov^er  extremities.  For 
example,  fixed  adduction  of  the  thigh  necessitates  an  upv^ard 
tilting  of  the  pelvis  whenever  the  limb  is  brought  into  the  nor- 
mal line,  whether  the  patient  is  standing,  sitting,  or  lying ;  and 
this  deformity  when  extreme  may  induce  lateral  curvature  even 
in  bedridden  patients. 

2.  CoMPEis'SATORY  DEFORMITY. — The  same  effect  is  some- 
times observed  in  certain  instances  of  inequality  of  the  length 
of  the  lower  extremities.  In  the  erect  posture  the  pelvis  is  tilted 
downward  on  one  side,  an  inclination  which  requires  lateral 
inclination  and  if  considerable,  rotation  of  the  spine  as  well. 
Simple  inequality  of  the  limbs  is  an  occasional  but  not  a  com- 
mon cause  of  fixed  deformity,  because  its  influence  ceases  in 
the  sitting  and  reclining  postures,  and  because  the  inequality  is 
so  often  compensated,  if  it  is  extreme,  by  walking  on  the  toe  or 
by  raising  the  sole  of  the  shoe. 

An  increase  in  the  length  of  a  limb,  such  as  may  be  caused  by 
a  fixed  equinus  of  the  foot,  seems  to  have  more  influence  in 
causing  secondary  deformity  than  does  shortening,  because  no 
attempt  is  made  to  comj)ensate  for  the  inequality. 

3.  Lateral  Curvature  Secondary  to  Paralysis. — Lat- 
eral deformity  of  the  spine  may  be  caused  indirectly  by  a  num- 
ber of  distinct  diseases  of  the  nervous  system,  but  in  this  con- 
nection only  one  need  be  considered — anterior  poliomyelitis. 
It  may  induce  deformity  by  distortion  of  a  lower  extremity  or 
by  inequality  in  the  length  of  the  limbs  due  to  retardation  of 
growth.     It  may  predispose  to  deformity  by  the  general  weak- 

X  ness  that  it  causes,  or  the  trunk  may  be  unbalanced  by  loss  of 
function  in  one  of  the  upper  extremities,  but  the  more  extreme 
cases  of  deformity  are  caused  by  unilateral  paralysis  of  the 
muscles  of  the  trunk.     As  a  result  the  expansion  of  one  side  of 


166 


OBTROPEDIC  SUBGEBT. 


the  thorax  is  interfered  with  and  the  unaffected,  or  less  affected, 
side  taking  on  increased  activity,  develops  at  the  expense  of  the 
disabled  part.  Thus,  the  convexity  of  the  curve  is  usually 
toward  the  sound  part. 

4.  Lateral    Curvatuke    Secondary   to   Disease    within^ 
THE  Thoracic  Walls. — The  most  common  cause  of  deformit;^ 
of  this  class  is  persistent  empyema.     The  lung  is  primarily  coi  ' 
pressed  by  the  effused  fluid,  and  its  function  is  finally  impai/ed 


Fig.  102. 


Fig.  103. 


Scoliosis  following  empyema  at 
the  age  of  two  years.  Present 
age  nineteen  years. 


Scoliosis  secondary  to  lumbar  Pott's  disease  in 
early  childhood. 


or  abolished  by  the  adhesions  that  form  between  it  and  the  chest 
wall,  as  well  as  by  the  extension  of  the  disease  to  its  structure. 
As  a  result,  the  side  of  the  chest  is  retracted  while  the  function 
of  the  unaffected  lung  is  increased  (Fig.  102).  Thus,  as  in 
paralysis,  the  spine  curves  with  the  convexity  toward  the  active 
side. 


LATERAL  CUBVATUBE  OF  THE  SPINE. 


167 


Other  affections  of  the  lungs  that  interfere  with  the  function 
of  one  side  may  induce  lateral  curvature,  but  the  influence  is 
less  marked  and  direct  than  in  empyema. 

5.  Incidental  Lateral  Cukvatuke. — Lateral  curvature 
may  be  caused  by  direct  injury  or  by  disease  of  the  spine;  for 
example,  by  fracture  or^by  Pott's  disease,  or  by  other  organic 


Fig.  104. 


Fig.  105. 


Congenital  scoliosis. 


Rhachitic   scoliosis. 


affections  of  the  spine  (Fig.  103).  Distortion  symptomatic  of 
sacroiliac  disease,  or  the  more  marked  deformity  caused  by 
sciatic  or  lumbar  neuritis  (Fig.  88),  may  if  persistent  finally 
induce  slight  permanent  deformity,  but  such  cases  hardly  de- 
serve special  consideration. 

6.  Lateral  Curvature  due  to  Occupation. — Lateral 
curvature  of  a  mild  degree  is  incidental  to  certain  occupations 
that  require  habitual  inclination  of  the  body.     It  is  said  to  be 


168 


OBTEOPEDIC  SUBGEBY. 


very  common  among  stone-cutters,  for  example.  Such  deform- 
ity developing  after  tlie  growth  of  the  body  has  been  attained  is 
of  interest  as  throwing  light  upon  the  etiology  of  the  ordinary 
form  of  lateral  curvature.  For  if  habitual  attitudes  can  thus^ 
change  the  contour  of  the  developed  spine,  it  is  evident  thaft 
similar  postures,  though  far  less  constant,  may  influence  the 

Fig.  106. 


Congenital   Lateral   Curvature. 

spine  of  a  growing  child,  particularly  in  one  predisposed  to  such 
distortion. 

7.  Congenital  Lateral  Cukvatuee. — Congenital  scoliosis 
may  occur  in  infants  otherwise  normal  due  apparently  to  a 
constrained  attitude  before  birth.  It  is  usually  associated,  how- 
ever, with  other  defects  or  deformities,  for  example,  with  cer- 


LATEBAL  CUBFATUBE  OF  THE  SPINE.  169 

vical  ribs,  elevation  of  the  scapula  and  the  like.  The  deformity 
may  be  apparent  at  birth  or  it  may  not  be  observed  until  later 
years,  when  examination  by  the  X-ray  shows  supernumerary,  de- 
ficient or  fused  vertebra  and  the  like  (Fig.  106). 

8,  Ehaciiitic  Lateral  Cukvatuee. — Khachitis  predisposes 
to  deformity  of  all  parts  of  the  body  by  lessened  resistance  of 
all  the  tissues.  As  is  well  known,  the  common  deformities  from 
this  cause  are  the  so-called  rhachitic  kyphosis  that  develops  in 
the  sitting  child,  and  the  distortions  of  the  lower  extremities 
in  those  who  stand  and  walk.  Lateral  curvature  of  the  spine 
sometimes  accompanies  the  kyphosis  in  those  who  do  not  walk, 
or  it  may  exist  independently  of  it.  The  lateral  inclination  is 
induced  doubtless  by  the  manner  of  sitting  or  by  the  manner  in 
which  the  child  is  supported  on  the  mother's  arm;  for  at  this 
period  of  rapid  growth  and  increased  susceptibility  to  deforming 
influences,  even  slight  and  temporary  causes  of  this  nature  may 
be  sufiicient  to  induce  the  distortion  (Fig.  105).  Again,  when 
the  child  begins  to  walk,  the  tilting  of  the  pelvis  due  to  distor- 
tion of  the  limbs,  for  example,  to  unilateral  knock-knee,  may 
also  serve  to  disturb  the  equilibrium  of  the  body  and  thus  to 
induce  lateral  distortion. 

How  common  rhachitic  lateral  curvature  may  be  it  is  impos- 
sible to  say,  but  if  all  rhachitic  infants  and  children  were  care- 
fully examined  this  deformity  would  be  discovered  in  many 
instances  in  which  its  existence  had  not  been  suspected. 

Mayer ^  examined  220  rhachitic  children  with  reference  to 
this  point,  and  in  all  but  3  found  scoliotic  deformity.  This  is 
not  in  accord  with  my  own  experience,  but  I  am  convinced  that 
rhachitis  is  of  far  greater  importance  in  the  etiology  of  lateral 
curvature  of  the  spine  than  is  generally  believed,  and  that  the 
larger  proportion  of  the  severe  and  intractable  cases  may  be 
traced  to  this  cause.  As  has  been  mentioned  rhachitic  scoliosis 
is,  practically  speaking,  equally  divided  between  the  sexes. 

In  about  15  per  cent,  of  the  cases  under  treatment  by  Trus- 
low  the  influence  of  one  or  more  of  the  causes  that  have  been 
enumerated  seemed  to  be  apparent,  viz. : 

Congenital  deformity   2 

Torticollis    2 

Empyema 4 

Anterior  poliomyelitis 3 

Inequality  of  the  legs  of  more  than  half  an  inch 6 

Ehachitis    13 

Total 30 

^Bull.  Medicale,  June  15,  1901. 


170 


ORTHOPEDIC  SUEGEEY. 


In  tlie  remaining  85  per  cent,  of  the  cases  the  direct  cause 
of  tlie  deformitv  was  uncertain. 

Hereditary  Influence. — By  manv  writers  the  influence  of  hered- 
ity is  considered  an  important  factor  in  the  etiology.  -  That 
there  is  such  an  intluence.  predisposing  to  disease  as  yell  as  to 
deformity,  is  undoulDted,  but  it  is  very  difficult  to  establish  its 


Fig.  10- 


u 


Posture  induced  by  improper  desli  and  chair.      (Scudder.) 


connection  with  ordinary  cases.  In  eleven  of  201  cases,  lateral 
curvature  was  present  in  either  the  father  or  mother  of  the 
patient ;  and  in  seventeen  others  a  brother  or  sister  of  the  patient 
was  deformed  in  a  similar  manner. 

Occupation. — As  occupation  may  induce  deformity  in  the 
adult,  and  one  looks  naturally  to  occupation  as  a  factor  in  the 
causation  of  lateral  curvature  in  childhood.  Occupation  in  this 
class  implies  school,  and  it  is  well  known  that  fatigue  during 
school  hours  may  induce  improper  postures,  especially  if  the 
chair  is  unsuitable  or  uncomfortable.  The  influence  of  habitual 
posture  is  indicated  in  the  statistics  of  lateral  curvature  among 
school-children  recorded  by  Scholder,  Werth,  and  Combe, ^  the 

^Bull.    Medicale,    June    15.    1901. 


LATERAL  CUBFATUEL:  OF  THE  SPINE. 


171 


proportion  of  deformity  steadily  rising  from  the  lower  to  the 
higher  classes  (Figs.  107  and  108).  Under  the  influence  of 
constantly  recurring  fatigue  an  improper  attitude  is  likely  to 
become  habitual,  its  character  being  influenced  by  the  arrange- 
ment of  the  light  or  by  the  shape  of  the  seat  or  desk.     When  a 

Fig.  108. 


Posture  induced  by   improper   chair.      (Scudder. ) 


habit  of  posture  has  been  acquired  it  is  likely  to  persist  when 
the  sitting  posture  is  assumed  elsewhere  than  at  school,  and  the 
greater  liability  of  girls  to  the  deformity  may  be  explained  in 
part  by  the  fact  that  they  sew,  or  read,  or  play  on  the  piano 
when  boys  are  usually  engaged  in  active  exercise. 

In  400  cases  of  lateral  curvature  under  treatment  at  the  Hos- 
pital for  Ruptured  and  Crippled,  the  occupation  and  habits  that 
may  have  influenced  the  deformity  were  recorded: 

Occupation : 

School  285 

Factory 19 

Clerk  13 

Domestic    8 

Millinery,  dressmaking,  etc 8 

Messenger    3 

Housewife   3 

Teacher 2 

No  occupation ^ 

Total 400 


172  OETHOPEDIC  SUBGEBT. 

Posture : 

Weight  on  right  foot 48 

Weight  on  left  foot 48 

91 

Carries  books  or  baby  on  right  arm 38    / 

Carries  books  or  baby  on  left  arm 36/ 

/      74 

Sits  at  desk  or  work  in  faulty  attitude 57 

Carries  heavy  load  on  one  shoulder 2 

Excessive  use  of  right  arm  in  occupation 3 

Total 232 

The  sitting  posture  is  not  the  only  one  in  which  improper 
attitudes  may  be  persistently  assumed,  for  even  posture  during 
sleep  may  influence  the  inclination  of  the  body  during  the  hours 
of  activity.  But  the  sitting  position  is  the  one  in  which  the 
muscular  support  is  most  likely  to  be  relaxed,  and  in  which  a 
tendency  toward  lateral  inclination  is  most  likely  to  be  acquired, 
since  children  do  not  often  retain  one  attitude  in  the  erect 
position  for  any  length  of  time.  Bradford  and  Lovett  record 
an  observation  of  the  attitudes  of  sixty-seven  healthy  adults 
undergoing  a  written  examination.  At  the  end  of  the  second 
hour  a  lateral  inclination  of  the  body  was  evident  in  all,  and  in 
three-fourths  of  the  number  to  the  right.  In  about  this  propor- 
tion of  the  cases  of  lateral  curvature  the  type  of  fixed  deformity 
is  to  the  left  in  the  lumbar  and  to  the  right  in  the  dorsal  region. 
Assuming  that  the  distortion  is  caused  or  influenced  by  the 
habitual  attitude  during  school  hours  it  would  appear  that  the 
primary  deformity  should  be  more  often  of  the  lumbar  region, 
for  in  the  sitting  posture  the  lumbar  lordosis  is  lessened  or  lost ; 
thus  the  bodies  of  the  vertebrae  in  the  lumbar  region  are  sub- 
jected to  greater  pressure  than  in  the  dorsal  region — a  pressure 
which  might  induce  the  accommodative  changes  in  the  bones 
that  accompany  persistent  deformity. 

The  possibility  of  distinguishing  the  varieties  of  lateral  cur- 
vature in  which  the  primary  distortion  is  lumbar  from  those  in 
which  it  is  dorsal,  by  the  flattening  of  the  dorsal  kyphosis  in 
the  former,  and  its  exaggeration  in  the  latter  instance,  has  been 
mentioned. 

Varieties  of  Deformity. — According  to  statistics  from  various 
sources,  about  three-fourths  of  the  well-developed  double  curves 
of  the  spine  are  convex  to  the  right  in  the  dorsal  and  to  the  left 
in  the  lumbar  region,  and,  as  the  distortion  of  the  thorax  is 
more  noticeable  of  the  two,  it  usually  classifies  the  deformity  as 
right  or  left.     The  dorsal  curvature  may  be  either  primary  or 


LATERAL  CUBVATUBE  OF  THE  SPINE.  173 

secondary,  and  the  relative  frequency  of  the  original  deformity, 
whether  lumbar  or  dorsal,  is  in  doubt,  with  the  probability  in 
favor  of  the  former. 

Summary  of  varieties  of  deformity  of  the  spine  under  treat- 
ment, tabulated  by  Dr.  Truslow: 

1.  Simple  anteroposterior  deformities: 

(a)  Kyphosis 10 

Kypholordosis    1 

Lordosis    1 

^     12 
Bound  Shoulders: 

(&)  Abducted  scapulae 7 

Elevated  scapulae 2 

^      9 

2.  Anteroposterior  abnormalities  most  marked,  but  accom- 

panied by  lateral  deviation: 

(a)  With  single  lateral  curve 14 

(&)  With  double  lateral  curves 16 

(c)  With  triple  lateral  curves 7 

~     37 

3.  Rotation  more  marked  than  lateral  deviation : 

(a)  With  double  lateral  curves 22 

(h)  With  triple  lateral  curves 8 

30 

4.  Lateral  deviation  more  marked  than  rotation;   direction 

of  the  curves: 
Eight  dorsal,  left  lumbar  type: 

(a)  Single   lateral   curve 22 

(&)  Double  lateral  curves 17 

(c)  Triple  lateral  curves 6 

^     99 
Left  dorsal,  right  lumbar  type : 

(a)  Single  lateral  curve 3 

(6)  Double  lateral  curves 8 

(c)  Triple  lateral  curves 3 

~^     14 
Total 201 

It  will  be  noted  that  in  twenty-one  cases,  anteroposterior  de- 
formity was  present  without  lateral  deviation,  and  that  in  thirty- 
seven  instances  it  was  accompanied  by  lateral  deviation.  In  the 
remaining  144  cases,  rotation  was  more  marked  than  lateral 
deviation  in  30  cases,  and  lateral  deviation  more  marked  than 
rotation  in  113.  In  the  entire  number  of  cases  in  which  lateral 
deviation  was  present  it  was  single  in  39  cases,  double  in  117 
cases,  triple  in  24  cases. 

In  890  cases  of  lateral  curvature  tabulated  by  Schulthess  the 
deformity  was  as  follows:^ 

'  Zeits.  f .  Orth.  Chir.,  1902,  Bd.  x. 


174  OBTHOPEDIC  SUBGEBY. 

Left.  Right./      Total. 

Total  scoliosis    (single  curve  affecting  the 

entire  spine) 173  ^  196 

Lumbar  scoliosis    (single  curve  limited  to 

the  lumbar  region)    63  34  97 

Lumbodorsal  scoliosis  (single  curve  limited 

to  lumbodorsal  region)    184  164  348 

Complicated  scoliosis: 

(a)  Eight  dorsal,  left  lumbar 191 

(6)  Left  dorsal,  right  lumbar 58  ...  249 

478  412  890 

It  will  be  noted  that  a  very  large  proportion  of  these  cases 
were  in  the  early  stage  of  deformity,  as  indicated  by  the  absence 
of  compensatory  curves;  that  in  80  per  cent,  of  the  293  cases  in 
which  the  curve  was  general  or  most  marked  in  the  lumbar 
region,  the  inclination  was  to  the  left ;  and  of  the  complicated  or 
more  fully  developed  cases  in  which  the  curve  was  double,  73 
per  cent,  were  of  the  right  dorsal,  left  lumbar  type. 

S3nQaptoms. — In  the  majority  of  cases  the  first  symptom  is 
the  deformity.  This  is  often  discovered  by  the  dressmaker  at 
the  age  when  the  clothing  is  made  to  fit  the  figure  more  closely. 
In  certain  instances  the  deformity  may  be  preceded  or  accom- 
panied by  pain.  This  was  present  to  a  greater  or  less  degree  in 
about  one-quarter  of  the  cases  examined  by  Truslow.  Pain  may 
be  simply  the  discomfort  or  the  "  dragging "  sensation  of 
fatigue,  usually  referred  to  the  lumbar  region,  or  it  may  be 
,severe  and  neuralgic  in  type.  The  latter  variety  is  more  com- 
mon in  the  cases  in  which  the  deformity  is  extreme.  It  is  said 
to  be  the  result  of  pressure  on  nerves,  but  this  cause  is  excep- 
tional in  ordinary  cases,  as  it  is  as  often  referred  to  the  convex 
as  to  the  concave  side.  When  the  deformity  is  extreme — for 
example,  when  the  ribs  and  the  iliac  crest  are  in  contact — direct 
pressure  may  explain  the  local  discomfort  referred  to  this  re- 
gion. There  are  also  more  general  symptoms  of  a  neurasthenic 
or  hysterical  character  that  may  be  due  in  part  to  the  deformity 
and  in  part  to  the  debility  of  which  it  may  be  a  result  or  accom- 
paniment. For  it  must  be  borne  in  mind  that  lateral  curvature 
is  one  of  the  postural  deformities  whose  development  is  favored 
by  general  weakness,  as  illustrated  by  the  fact  that  it  is  often 
accompanied  by  other  deformities  of  similar  nature,  particu- 
larly by  the  weak  foot.  Deformities  of  this  class  that  are  in- 
duced by  weakness,  in  their  turn  tend  to  prolong  and  to  aggra- 
vate it  by  hampering  normal  development  and  normal  function. 

In  many  instances  symptoms  of  weakness  and  awkwardness 
precede  the  deformity.     Truslow  states  that  in  a  large  proper- 


LATERAL  CUBVATUEE  OF  THE  SPINE.  175 

tion  of  the  cases  investigated,  tlie  patients  had  been  distinctly 
less  active  than  their  companions,  that  they  did  not  enjoy  exer- 
cise, and  were  inclined  to  lead  sedentary  lives.  Teschner^  has 
called  attention  to  the  same  peculiarity.  He  states  that  the 
patients  are  often  indifferent,  apathetic,  and  lazy.  He  has 
noted  also  a  peculiar  lack  of  co-ordination  and  muscular  control 
as  a  common  accompaniment  of  the  deformity.  These  symp- 
toms apply  particularly  to  adolescence,  the  period  of  rapid 
growth  and  instability,  when  any  latent  deformity  or  weakness 
is  likely  to  be  exaggerated.  In  younger  subjects  such  symptoms 
are  far  less  marked  or  are  absent.  In  the  cases  in  which  the 
deformity  is  extreme,  symptoms  due  to  interference  with  the 
respiratory  and  circulatory  apparatus,  or  to  displacement  of  the 
abdominal  organs,  may  be  present.  Such  symptoms  are,  how- 
ever, rather  unusual  in  cases  of  the  ordinary  type. 

Diagnosis., — Posture, — When  the  patient  stands  with  the  back 
and  hips  bare,  the  lateral  inclination  of  the  body  and  a  corre- 
sponding asymmetry  of  the  trunk  are  usually  apparent,  even  in 
the  earliest  stage  of  the  affection.  For,  as  has  been  stated,  the 
habitual  assumption  of  the  deforming  attitude  precedes  fixed 
changes  in  and  about  the  spine,  and  this  attitude  will  appear 
when  the  patient  is  asked  to  stand  for  inspection.  If  the  incli- 
nation of  the  body  is  toward  the  left  (Fig.  91),  the  left  arm 
will  hang  in  close  apposition  to  its  lateral  border,  while  on  the 
right  side  an  interval  will  appear  between  the  arm  and  the 
trunk.  If  there  is  a  slight  lumbar  curve  to  the  left  (Fig.  93), 
the  right  iliac  crest  will  be  accentuated.  The  curvature  in  the 
dorsal  region  raises  one  shoulder  (Fig.  103),  the  scapula  on  the 
affected  side  projects,  and  the  distance  between  its  posterior 
border  and  the  median  line  is  increased.  Rotation  of  the  spine 
is  shown  by  the  fulness  or  projection  of  one  side  accompanied 
by  a  corresponding  flatness  or  concavity  on  the  other.  This  is 
more  noticeable  when  the  patient  bends  the  body  forward  so 
that  the  horizontal  plane  of  the  back  is  brought  into  view  (Fig. 
92).  Corresponding  changes,  though  of  a  less  marked  degree, 
appear  on  the  anterior  surface  of  the  body;  for  example,  the 
apparent  diminution  in  the  size  of  the  mamma  on  the  side  of 
the  convexity  and  its  relative  depression  or  elevation  may  at- 
tract attention. 

It  is  probable  that  a  change  in  the  anteroposterior  contour 
of  the  spine  precedes,  in  many  instances,  the  lateral  deviation. 

^  Medical  Kecord,  December  16,  1893. 


176  OBTHOPEDIC  SUBGEBT. 

Thus,  a  general  droop  of  the  body  associated  with  round  shoul- 
ders and  a  flattened  chest  may  be  regarded  as  a  predisposing 
cause.  / 

Mobility.- — Habitual  posture  implies  disuse  of  certain  atti- 
tudes and  motions,  thus  limitation  of  the  normal  flexibilit;^  of 
the  spine  is  one  of  the  earliest  signs  of  progressive  defortnity. 
The  test  of  the  motion  of  the  different  regions  of  the  spine  is,  ■ 
therefore,  an  essential  part  of  the  examination.  To  test  the 
motion  in  the  lumbar. region,  one  fixes  the  pelvis  with  the  hands 
while  the  patient  sways  the  body  in  the  four  directions  and 
rotates  it  from  side  to  side.  It  is  suggested  by  Bradford  and 
Lovett  that  direct  lateral  flexibility  may  be  tested  by  placing 
blocks  of  wood  under  one  foot  until  the  limit  of  lateral  flexion 
is  reached,  as  shown  by  the  inability  of  the  patient  to  hold  the 
elevated  limb  in  the  extended  position.  The  experiment  is  then 
repeated  on  the  opposite  side.  The  flexibility  of  the  upper  part 
of  the  trunk  may  be  tested  by  fixing  the  part  below  with  the 
hands  while  the  patient  flexes,  extends,  and  rotates  the  body.  It 
is  important,  also,  to  test  the  range  of  motion  at  the  shoulder- 
joints.  The  normal  individual  should  be  able  to  hold  the  arms 
extended  directly  above  the  head  without  increasing  the  lumbar 
lordosis.  In  many  instances,  however,  it  will  be  found  that 
there  is  a  marked  restriction  of  this  motion;  in  fact,  such  re- 
striction is  almost  always  an  accompaniment  of  so-called  round 
shoulders. 

The  height  and  weight,  the  circumference  and  the  expansion 
of  the  chest  should  be  recorded,  and  a  test  of  the  muscular 
strength,  not  only  of  the  muscles  of  the  trunk,  but  of  the  mem- 
bers as  well,  is  of  advantage  as  throwing  light  on  the  etiology 
and  indicating  the  general  line  of  treatment. 

Record. — The  most  reliable  of  the  graphic  records  to  be  used 
in  connection  with  the  history  are  photographs.  The  patient 
may  stand  behind  a  thread  screen  (Fig.  109)  in  the  habitual 
attitude.  The  spinous  processes,  the  iliac  crests,  and  the  angles 
of  the  scapulse  having  been  marked,  the  exact  amount  of  lateral 
deviation  of  the  trunk  will  be  shown.  The  rotation  may  be  indi- 
cated also  by  photographing  the  patient  in  the  recumbent  posture. 

The  rotation  of  the  spine  is  the  most  important  indication  of 
deformity.  This  may  be  recorded  with  sufficient  accuracy  by 
taking  direct  tracings  of  the  trunk  at  fixed  points  b}^  means 
of  a  lead  or  zinc  tape  while  the  patient  lies  in  the  recumbent 
posture. 


LATERAL  CUBFATUBE  OF  THE  SPINE. 


177 


Fig.  109. 


At  the  Hospital  for  Ruptured  and  Crippled  the  shadow  of  the 
trunk  cast  by  an  electric  light  at  a  fixed  distance  is  traced  upon 
a  large  sheet  of  paper.  Upon  this  outline  the  position  of  the 
more  important  landmarks  is  indicated.  The  degree  of  rotation 
is  shown  by  transverse  tracings  and  the  line  of  the  spinous 
processes  is  ascertained  by  ap- 
plying a  broad  strip  of  ad- 
hesive plaster  to  the  back 
upon  which  the  tip  of  each 
spinous  process  is  marked. 
The  anteroposterior  outline 
of  the  spine  should  be  re- 
corded, also  the  general  atti- 
tude and  the  presence  or 
absence  of  other  evidences  of 
weakness  such  as  knock-knees 
and  weak  feet. 

Prognosis. — lu  the  devel- 
opment of  lateral  curvature 
there  is  doubtless  a  prelimi- 
nary or  predisposing  stage — 
a  stage  of  progression  and  a 
stage  of  arrest.  All  deformi- 
ties of  this  class  are  more 
likely  to  progress  during  the 
growing  period.  They  are 
likely  to  become  stationary 
when  the  period  of  growth  is 
completed.  Thus,  the  prog- 
nosis is  worse  when  the  de- 
formity begins  at  an  early 
age  than  when  it  first  appears 
in    adolescence.       The    most 

extreme  and  intractable  of  the  simple  cases  are  the  result  of 
rhachitis,  in  which  the  deformity  appearing  in  infancy  or  early 
childhood  has  increased  with  the  growth  of  the  child. 

If  the  causes  of  deformity  are  such  that  they  operate  to  check 
the  equal  development  of  the  affected  part,  the  prognosis  is  even 
more  directly  influenced  by  the  age  of  the  patient.  For  ex- 
ample, empyema,  even  if  the  lung  is  irreparably  damaged,  does 
not  cause  appreciable  deformity  in  the  adult,  but  in  childhood 
the  functional  activity  and  the  growth  of  the  side  of  the  thorax 
12 


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Children's    Hospital    Report. 


178  .  OBTHOPEDIC  SUBGEBY. 

are  checked  in  addition  to  tlie  direct  effect  of  the  adhesions  and 
contractions  due  to  the  disease;  thus,  the  deformity  is  likew  to 
be  progressive  in  spite  of  the  treatment.  The  same  is  trAe  of 
paralytic  deformity.  In  the  ordinary  type  of  lateral  cui^^ature 
in  the  adolescent  girl  the  prognosis  is  influenced,  of  cotirse,  by 
the  general  condition  of  the  patient  and  by  the  character  of  the 
occupation.  As  far  as  the  local  deformity  is  concerned,  the 
prognosis  as  regards  improvement  or  cure  depends  in  great 
measure  upon  the  fixed  changes  that  have  taken  place,  and  upon 
the  degree  of  voluntary  and  involuntary  rectification  that  is 
possible.  In  some  instances  the  postural  distortion  may  be  con- 
siderable, yet  the  fixed  deformity  may  be  very  slight,  while  in 
other  instances  the  fixed  rotation  of  the  spine  may  be  marked, 
although  the  lateral  distortion  is  less  noticeable. 

A  single  curve  is  more  amenable  to  treatment  than  is  a  double 
or  triple  distortion,  because  it  indicates  an  earlier  stage  of  de- 
formity and  because  the  treatment  may  be  more  effective  when 
applied  to  one  deformity  than  to  several.  If,  however,  the  single 
curve  is  fixed,  the  appearance  of  a  secondary  or  compensatory 
curve  at  another  part  of  the  spine  is  probable,  in  spite  of  pre- 
ventive treatment. 

In  the  majority  of  cases,  fixed  deformity  of  the  spine  as  indi- 
cated by  rotation  is  already  present  when  the  patient  is  brought 
for  treatment.  This  fixed  deformity  might  be  overcome  doubt- 
less in  certain  cases,  and  complete  cure  might  be  obtained  were 
all  conditions  favorable.  But  in  the  ordinary  sense  a  cure  means 
the  relief  of  symptoms,  the  checking  of  the  progress  of  deform- 
ity, and  the  'restoration  of  the  general  symmetry  of  the  trunk. 
Such  a  cure  may  be  obtained  in  most  instances.  The  deformity 
of  the  spine  becomes  symmetrically  divided  on  either  side  of  the 
median  line,  the  changes  incident  to  maturity,  particularly  the 
increased  amount  of  adipose  tissue,  serve  to  conceal  the  irregu- 
larities of  the  outline,  and  the  history  of  the  distortion  is 
completed. 

In  certain  instances,  particularly  in  the  more  extreme  cases, 
the  deformity  may  increase  in  adult  life  and  even  in  old  age. 
In  this  type,  the  symptoms  of  discomfort  and  actual  pain  may 
be  troublesome  throughout  life,  especially  in  the  overworked 
and  debilitated  class.  The  symptoms  directly  incident  to  the 
compression  and  distortion  of  the  internal  organs  have  been 
mentioned. 

The  great  majority  of  cases  that  develop   or  that   are  dis- 


LATERAL  CUEFATUBE  OF  THE  SPINE.  179 

covered  in  adolescence  progress  for  a  time  and  come  to  an  end 
on  the  cessation  of  growth,  causing  finally  no  symptoms  other 
than  the  loss  of  symmetry  that  may  be  more  or  less  satisfac- 
torily concealed  by  the  art  of  the  dressmaker  and  by  the  corset. 

It  would  appear,  then,  that  lateral  curvature  of  the  spine  is 
always  of  sufiicient  gravity  to  merit  treatment  and  supervision 
until  its  cure  or  arrest  is  assured.  If  its  discovery  leads  to  the 
improvement  of  the  general  condition  and  to  the  avoidance  of 
unhealthful  influences  it  may  be  even  of  benefit  to  the  patient. 

Summary.^ — Lateral  curvature  in  a  young  child  is  of  far 
greater  importance  than  in  an  older  subject  because  of  the  prob- 
ability of  an  increase  of  deformity.  Extreme  deformity  is 
always  a  source  of  weakness  and  usually  of  discomfort  to  the 
patient.  Incipient  deformity  may  be  cured  and  cure  is  not 
impossible  even  when  deformity  is  luore  advanced,  but  in  this 
more  than  in  any  other  postural  deformity,  absolute  cure  implies 
.  early  diagnosis  and  prevention,  rather  than  the  correction  of 
fixed  distortion. 

The  progress  of  the  deformity  of  the  ordinary  type  is  indi- 
cated : 

1.  The  habitual  assumption  of  an  attitude  simulating  de- 
formity. 

2.  Limitation  of  motion  in  the  directions  opposed  to  the 
habitual  attitudes. 

3.  Fixed  lateral  deviation  of  the  spine  accompanied  by  rota- 
tion or  twisting  of  the  column. 

One  rarely  has  the  opportunity  to  note  the  development  of 
lateral  curvature,  and  when  patients  are  brought  for  treatment 
fixed  deformity  is  usually  present.  It  is  very  difficult  to  en- 
tirely overcome  fixed  distortion,  while  it  is  comparatively  easy 
to  correct  simple  postural  deformity  in  which  the  secondary 
changes  are  absent  or  but  slightly  advanced.  On  this  account 
it  has  been  customary  to  divide  lateral  curvature  into  two  classes 
— the  true  and  the  false — or  to  speak  of  rotary  lateral  curvature 
as  distinct  from  lateral  curvature.  Thus,  the  term  ,  true  or 
rotary  curvature  would  be  limited  to  those  cases  in  which  the 
changes  are  fixed  and  in  which  cure  is  practically  impossible, 
while  false  or  simple  or  postural  lateral  curvature  would  include 
the  early  or  curable  class.  But  as  the  two  forms  are  simply 
stages  in  the  same  process  it  would  seem  preferable  to  speak  of 
the  incipient  and  the  later  stages  of  lateral  curvature,  or  of 
reducible  or  irreducible  deformity,  the  distinctions  that  are 
made  in  classifying  distortions  of  similar  origin  elsewhere. 


180 


OSTHOPEDIC  SUEGESY. 


This  j)oint  of  view  is  of  advantage  because  it  relieves  the  sub- 
ject of  much  of  the  obscurity  that  has  resulted  from  this 
arbitrary  division.  It  emphasizes  the  fact,  also,  that  the  habit- 
ual assumption  of  an  improper  attitude  that  simulates  deformity 
is  the  first  step  toward  permanent  distortion,  particularly  in 
individuals  who  by  inheritance  or  by  constitutional  tendency 
or  by  occupation  are  predisposed  to  it. 

Prevention  of  Deformity. — Prevention  includes  the  avoidance 
of  all  the  predisposing  or  exciting  causes  of  weakness  as  well  as 
of  deformity.     These  it  is  hardly  necessary  to  enumerate. 

The  first  and  most  important  preventive  measure  is  the  dis- 
covery of  deformity  or  the  tendency  to  deformity  at  a  time 
when  it  may  be  checked  or  cured.  To  discover  deformity  at 
this  period  of  its  development  one  must  look  for  it,  thus  the 

Fig.  110. 


Adjustable   school   desks   and  seats.      Sclieiber   and   Klein.      (Redard.) 


regular  inspection  of  the  naked  bodies  of  the  children  under 
his  care  should  become  a  routine  practice  of  the  family  phy- 
sician. Deformity  in  this  sense  includes  not  only  fixed  distor- 
tions, but  improper  attitudes  and  postures  of  every  variety  as 
well. 

The  importance  of  the  attitude  which  is  habitually  assumed 
during  occupation  has  been  mentioned.  Therefore,  the  pro- 
vision of  proper  desks  and  seats  for  school-cJiildrcn  is  a  very 
essential  part  of  preventive  treatment. 

The  seat  of  the  chair  should  be  deep  enough  to  support  the 
thiffhs,  yet  it  should  not  interfere  with  flexion  at  the  knees.     It 


LATERAL  CUBVATUBE  OF  THE  SPINE.  181 

should  be  of  such  height  as  to  allow  the  feet  to  rest  firmly  on  the 
floor,  and  it  should  be  inclined  slightly  backward.  The  back  of 
the  chair  should  extend  to  about  the  level  of  the  shoulders;  it 
should  be  inclined  slightly  backward,  but  arched  somewhat  for- 
ward in  the  lumbar  region  in  order  to  conform  to  the  normal 
lordosis  when  the  child  sits  in  the  erect  posture.  The  desk 
should  be  as  close  to  the  body  as  is  possible,  so  that  the  child 
need  not  lean  forward  when  reading  or  writing.  The  height  of 
the  desk  should  be  slightly  less  than  the  level  of  the  elbows  when 
the  child  sits  erect,  and  the  inclination  should  be  sufficient  to 
hold  the  book  at  the  proper  distance  from  the  eyes  (Figs.  110 
and  111).  The  vertical  handwriting  is  of  advantage  in  that  the 
children  are  taught  to  face  the  desk  squarely,  as  contrasted  with 
the  lateral  twist  of  the  body,  the  usual  attitude  for  writing. 

Treatment. — The  treatment  of  rotary  lateral  curvature  of 
the  spine  does  not  differ  in  character  from  the  treatment  of 
any  other  weakness  or  deformity,  but  as  the  application  of  the 
treatment  is  difficult  the  results  are  far  from  definite  and  satis- 
factory. This  explains,  doubtless,  the  apparently  opposing 
theories  and  methods  of  treatment  that  are  still  advocated. 

Principles  of  Treatment. — The  principles  of  the  treatment  of 
any  form  of  weakness  not  directly  induced  by  disease  may  be 
summarized  as  follows : 

1.  To  correct  deformity. 

2.  To  overcome  all  restriction  to  passive  motion. 

3.  To  strengthen  the  weakened  muscles,  especially  those 
whose  action  is  opposed  to  habitual  deformity. 

4.  To  prevent  as  far  as  may  be  overfatigue  and  predisposing 
postures. 

5.  To  support  the  weak  part  by  a  brace  if  deformity  cannot 
be  prevented  otherwise. 

In  applying  these  principles  to  the  treatment  of  the  distorted 
spine,  the  removal  of  restriction  to  passive  motion  in  all  direc- 
tions, is  difficult  because  of  the  variety  of  muscles  and  other' 
tissues  that  may  have  become  involved,  and  because  the  bodies 
of  the  vertebrae  lying  within  the  trunk,  of  which  the  distortion 
is  always  greater  than  of  the  spinous  processes,  can  be  only 
indirectly  affected  by  voluntary  or  by  passive  movements. 

The  cultivation  of  the  muscular  system,  and  particularly  of 
those  muscles  whose  action  is  opposed  to  the  habitual  deformity, 
as  applied  to  the  trunk,  is  difficult,  because  there  are  in  nearly 
all  developed  cases  two  curves,  the  one  primary  and  the  other 


182 


OBTHOPEDIC  SUBGEBY. 


secondarj,  in  direction  directly  opposed  to  one  another.  These 
opposing  curves  are  supplied  in  great  j)art  by  the  same  muscles, 
and  it  is  difficult  by  voluntary  effort  to  lessen  the  convexity  of 
one  without  at  the  same  time  increasing  that  of  the  other. 

The  avoidance  of  predisposing  attitudes  and  fatigue  is  espe- 
cially difficult  because  the  restful  sitting  posture  is  that  v^^hich 
induces   deformity.      Thus,   only  in   recumbency  is  the  spine 

Fig.  111. 


Adjustable  school   seat.      (Miller  and   Stone.) 


entirely  relieved  from  weight,  and  even  at  such  times  the  de- 
formity may  be  favored  by  the  habitual  attitude  of  the  patient. 

Finally  the  spine  cannot  be  supported  without  at  the  same 
time  restraining  its  normal  motion.  'Nor  is  any  brace  perfectly 
efficient,  for  while  it  may  prevent  the  lateral  deviation  it  can 
exercise  little  direct  action  on  the  rotation  of  the  spinal  column. 

It  is  apparent  then  that  it  is  not  the  difficulty  of  formulating 
principles,  but  the  difficulty  of  applying  them  that  makes  the 
therapeutics  of  rotary  lateral  curvature  of  the  spine  perplex- 
ing. In  practice  one  must  recognize  the  limitations  of  all  sys- 
tems of  treatment  as  applied  to  this  particular  deformity,  and 
select  and  combine  methods  that  may  be  most  applicable  to  the 
particular  case  under  treatment. 


LATEEAL  CUBVATUBE  OF  THE  SPINE.  183 

For  example,  in  the  treatment  of  rliacliitic  scoliosis  in  a  young 
child  one  cannot  count  upon  the  voluntary  assistance  of  the 
patient;  therefore,  treatment  by  simple  gymnastic  exercises  is 
impracticable.  In  this  class  of  cases  forcible  correction  of  the 
deformity  and  retention  by  a  support  combined  with  massage 
and  methodical  manual  correction  and  even  the  removal  of 
superincumbent  v^eight  by  recumbency  on  the  stretcher  frame 
would  be  treatment  of  selection.  By  such  means  one  may  expect 
at  this  period  of  rapid  growth  to  induce  a  transformation  of  the 
deformed  vertebral  bodies  to  an  approximation  at  least  of  the 
normal.  The  correction  of  deformity,  which  must  almost  in- 
evitably increase  with  the  growth  of  the  patient  would  quite 
outweigh  the  disadvantage  of  depriving  the  muscles  of  their 
normal  stimulus  during  the  corrective  period  of  treatment. 

In  the  ordinary  type  of  mild  deformity  in  older  subjects,  one 
would  expect  to  attain  the  best  results  by  gymnastic  training 
and  by  regulation  of  the  postures.  Although  even  in  this  class 
supports  may  be  of  service,  if  by  such  means  the  trunk  may  be 
held  in  an  overcorrected  attitude  until  the  deformity  habit  is 
overcome. 

The  advisability  of  a  change  of  occupation  has  been  men- 
tioned. It  is  probable  that  if  the  patient  with  incipient  or  even 
more  pronounced  curvature  of  the  spine  were  removed  from 
school,  were  transferred  to  the  country  where  during  the  succeed- 
ing years  of  childhood  and  adolescence  much  of  the  time  might 
be  passed  in  active  exercise  in  the  open  air,  the  final  result 
would  compare  very  favorably  with  that  attained  by  active 
treatment  under  less  favorable  circumstances.  Such  complete 
change  of  occupation  and  surroundings  is,  of  course,  imprac- 
ticable in  most  instances.  Lateral  curvature  of  the  spine  is  not 
a  serious  disease,  it  is  simply  an  insidious  distortion  which 
rarely  causes  more  than  comparatively  slight  discomfort.  It  is 
usually  overlooked  in  the  incipient  stage  when  it  might  be 
checked  or  cured,  and  when  the  deformity  finally  attracts  atten- 
tion it  is  often  no  longer  amenable  to  correction.  Under  these 
circumstances,  with  the  uncertainty  that  exists  as  to  the  ultimate 
prognosis,  the  tediousness  of  treatment  which  cannot  offer  the 
assurance  of  definite  cure,  it  is  not  strange  that  the  affection  is 
not  one  for  the  treatment  of  which  any  considerable  sacrifice  is 
considered  essential. 

A  third  class  of  cases  would  include  the  fixed  deformity  in 
older  subjects,  many  of  whom  are  obliged  to  assume  in  their 


184  ORTHOPEDIC  SUBGEBT. 

occupations  attitudes  that  predispose  to  deformity.  In  the  treat- 
ment of  this  class  a  support  to  relieve  discomfort  and  to  prevent 
exaggerated  distortion  may  be  essential. 

Thus,  there  are  four  classes  or  types  of  scoliosis  in  which 
distinct  methods  of  treatment  may  be  employed. 

1.  Curvatures  in  very  young  children,  in  which  correction 
and  fixation  are  indicated  in  the  hope  of  inducing  a  transforma- 
tion of  the  bones  and  other  tissues  by  natural  outgrowth. 

2.  The  milder  degrees  of  deformity  for  which  treatment  by 
exercises  and  by  favoring  postures  is  that  of  selection,  and  in 
which  support  is  a  temporary  and  incidental  adjunct. 

3.  The  more  advanced  cases  in  which  support  should  be  com- 
bined with  corrective  exercises. 

4.  Fixed  deformity  in  older  subjects,  and  those  cases  caused 
by  disease ;  as,  for  example,  by  paralysis,  by  empyema  and  the 
like,  for  which  constant  support  may  be  required. 

As  a  rule,  however,  no  absolute  therapeutic  distinction  can  be 
made,  and  treatment  by  exercises  and  postures  should  be  em- 
ployed whenever  practicable  in  all  cases,  whether  supports  are 
used  or  not. 

Posture  and  Exercises. — Whatever  may  have  been  the  original 
cause  of  the  distortion  of  the  spine  and  whatever  may  be  its 
degree  it  is  more  marked  when  the  patient  is  fatigued.  Fatigue 
in  the  normal  individual  is  shown  by  an  increase  of  the  normal 
anteroposterior  curves;  fatigue  in  the  deformed  subject  causes 
an  increase  in  the  pathological  curves.  It  requires  far  more 
muscular  effort  to  hold  the  deformed  spine  in  the  best  possible 
attitude  than  to  hold  the  normal  spine  in  the  correct  posture. 
Motion  in  the  normal  spine  is  as  free  in  one  direction  as  in 
another,  and  it  simply  requires  a  proper  balancing  of  the  muscu- 
lar force  to  hold  it  in  the  median  line.  But  when  there  is  a 
fixed  deformity,  to  overcome  which,  even  in  part,  requires  the 
conscious  effort  of  the  patient,  it  is  evident  that  on  the  relaxa- 
tion of  this  effort  the  spine  will  sink  back  into  the  habitual 
posture.  The  more  confirmed  the  deformity  the  greater  must 
be  the  effort  to  overcome  it,  and  the  more  rapidly  will  fatigue 
be  manifest.  Fatigue,  or,  rather,  the  relaxation  of  conscious 
muscular  effort,  is  favored  by  attitudes  that  do  not  require  the 
balancing  action  of  the  muscles.  For  example,  the  sitting  pos- 
ture during  school  hours  favors  deformity,  while  the  constant 
alternation  of  postures  in  work  or  play  that  requires  muscular 
activity  opposes  it.     Thus,  the  selection  of  occupations,  or,  at 


LATERAL  CURVATURE  OF  THE  SPINE.  185 

least,  the  restriction  of  the  time  passed  in  inactive  postures,  is 
an  important  part  of  treatment. 

As  improper  attitudes  are  favored  by  weakness  of  muscles, 
and  as  the  maintenance  of  the  best  possible  position  requires  a 
greater  expenditure  of  muscular  force  than  is  required  in  the 
normal  individual,  the  strengthening  of  all  the  muscles  of  the 
body,  and  particularly  of  those  of  the  back,  by  gymnastic  exer- 
cises, even  beyond  the  normal  standard,  is  the  most  important 
indication  in  treatment. 

One  of  the  most  effective  systems  of  treatment  by  gymnastics 
is  that  advocated  by  Teschner,  of  New  York.  On  the  theory 
that  lateral  curvature  is  induced  by  or  that  its  development  is 
favored  by  a  general  lack  of  muscular  strength  and  lack  of  mus- 
cular control  and  co-ordination,  Teschner  urges  the  necessity  of 
the  systematic  cultivation  of  all  the  muscles  of  the  body  as  well 
as  those  of  the  trunk,  the  part  particularly  at  fault.  He  also 
insists  upon  the  importance  of  exercising  each  muscular  group 
to  the  point  of  fatigue  on  the  theory  that  a  muscle  cannot  be 
developed  to  its  full  capacity  unless  it  is  thoroughly  fatigued  by 
uninterrupted  automatic  contractions  and  relaxations.  The 
term  automatic  implies  that  the  patient  shall  be  so  thoroughly 
trained  in  the  rhythmical  movements  that  they  require  no 
thought  for  their  performance.  Thus,  ease  and  grace  may 
replace  awkwardness  and  inco-ordination. 

The  system  is  modified  from  one  taught  by  Attilla,  a 
"  trainer  of  strong  men."  It  consists  of  a  series  of  exercises 
with  light  dumb-bells,  and  it  is  supplemented  by  so-called  heavy 
work.  The  exercises  are  designed  for  systematic  cultivation  of 
all  the  muscles  of  the  body,  the  heavy  work  more  directly  for 
the  correction  of  the  deformity  of  the  spine. 

General  Exercises.. — The  exercises  should  be  performed  before 
a  mirror,  the  patient  being  clad  in  a  close-fitting  rowing  suit,  so 
that  the  attitudes  may  be  constantly  observed  by  the  patient  and 
by  the  instructor.  The  greatest  attention  is  paid  to  the  perfec- 
tion of  the  alternating  movements  of  the  limbs  in  order  that 
they  may  become  in  time  purely  automatic  in  character.  Dur- 
ing the  performance  of  the  exercises  the  patient  holds  himself 
in  the  best  possible  position. 

These  exercises  were  described  and  illustrated  by  Teschner  in 
the  Annals  of  Surgery  for  August,  1895,  from  which  they  are, 
with  his  permission,  reproduced. 

"  A  pair  of  dumb-bells,  weighing  from  one-half  to  five  pounds 


186 


OBTEOFEDIC  SUBGEBY. 


each,  according  to  the  ability  of  the  patient,  is  used  in  a  series 
of  twentj-six  exercises. 

Fig.  113.  Fig.  114. 


Fig.  112. 


Fig.  115. 


Fig.  116. 


"The  Exercises. — The  patient  stands  erect,  the  heels  to- 
gether, the  toes  apart,  the  knees  thoroughly  extended,  the  ab- 
domen retracted,  the  chest  high,  the  head  well  poised,  and  the 


LATERAL  CUBVATUBE  OF  THE  SPINE. 


187 


patient  looking  intently  and  sharply  into  his  or  her  own  eyes 
in  the  mirror,  the  lips  being  evenly,  but  not  too  firmly,  closed, 
and  the  facial  mnscles  in  repose.  The  patient  should  breathe 
easily  and  regularly  while  exercising  (Figs.  112  and  113). 

"  1.  The  upper  extremities  are  fully  extended  downward,  the 
forearms  supinated,  the  elbows  remaining  close  to  the  sides  of 
the  body,  and  the  u]3per  arms  being  fixed ;  the  forearms  are 
alternately  and   automatically  fully  flexed  and   extended,   the 


Fig.  117. 


Fig.  118. 


wrists  and  entire  body  being  fixed  and  immovable.  Twenty  to 
fifty  times  (Fig.  114). 

"  2.  The  same  position  and  exercise,  except  that  the  forearms 
are  fully  pronated,  and  remain  so  during  alternate  flexion  and 
extension.     Twenty  to  fifty  times  (Fig.  115), 

"  3.  Both  bells  over  the  shoulders,  the  arms  abducted  at  right 
angles  to  the  body  and  in  the  same  vertical  and  horizontal 
planes,  the  forearms  fully  flexed  upon  the  arms,  and  the  wrists 
fully  flexed  upon  the  forearms.  The  forearms  and  wrists  are 
then  alternately  and  automatically  extended  and  flexed.  Ten  to 
twenty  times  (Fig.  116). 

"  4.  The  same  position  and  exercises,  except  that  both  upper 
extremities  are  flexed  and  extended  at  the  same  time.  Five  to 
fifteen  times  (Fig.  117). 

"  5.  Both  upper  extremities  fully  extended  forward  on  a  level 


188 


ORTHOPEDIC  SURGEBT. 


with  the  shoulders,  the  dorsum  of  the  hands  outward.  They 
are  then  fully  and  forcibly  abducted  on  a  horizontal  plane,  the 
patient  at  the  same  time  raising  the  body  upon  the  toes,  and  are 


Fig.  119. 


Fig.  120. 


Fig.  121. 


Fig.  122. 


LATERAL  CUBVATU'RE  OF  THE  SPINE. 


189 


then  permitted  to  recede  to  the  original  position,  the  body  rest- 
ing on  the  toes  and  heels,  the  elbows  and  wrists  still  rigid,  the 
bells  not  being  permitted  to  touch  as  they  approximate  each 
other.    Five  to  ten  times  (Fig.  119). 


Fig.  123. 


Fig.  124. 


Fig.  l2.^. 


Fig.  126. 


Fig.  127. 


190 


OBTHOPEDIC  SUBGEB¥. 


"  6.  Bells  in  tlie  position  of  exercises  ISTo.  3  and  ISTo.  4.  The 
arms  are  fully  extended  alternately  above  the  head.  Ten  to 
twenty  times  (Fig.  120). 

"  7.  Bells  in  front  of  the  thighs,  forearms  pronated,  and  bells 
alternately  raised  to  the  level  of  the  shoulders,  the  elbows  and 
Avrists  being  fixed.     Ten  to  twenty  times  (Fig.  121). 

"  8.  The  arms  abducted  at  right  angles  to  the  body,  the  bells 
rotated  raj)idly  and  forcibly  forward  and  backward,  the  elbows 
being  fixed.     Five  to  ten  times  (Fig.  122). 

"9.  The  arms  abducted  at  right  angles  to  the  body,  the 
thumbs  upon  one  ball  of  each  bell,  the  hands  circumducted  for- 


FiG.  128. 


Fig.  129. 


/■■■"  7""/\  \  ^ 


ward  from  above  downward,  the  ball  upon  which  the  thumbs  rest 
describing  circles,  the  elbows  and  shoulders  being  fixed.  Five 
to  ten  times  (Fig.  122). 

"  10.  The  same  as  'No.  9,  the  hands  being  circumducted  back- 
ward.    Five  to  ten  times  (Fig.  123). 

"11.  The  bells  to  the  side.  Eight  face  upon  left  heel,  then 
placing  the  foot  at  right  angles  to  right  foot  opposite  the  arch, 
the  knees  slightly  fiexed,  the  right  hand  at  waist-line  against 
the  body,  the  bell  being  perpendicular.  Second  part  of  motion : 
strike  from  the  shoulder  to  level  of  the  face,  advancing  a  step 
upon  the  left  foot,  rapidly  extending  the  right  thigh  and  leg,  the 
right  foot  being  fixed  u.pon  the  floor,  and  quickly  back  to  posi- 
tion.    Ten  to  fifteen  times  (Figs.  124  and  125). 


LATEBAL  CUEVATUBE  OF  THE  SPINE. 


191 


"  12.  Exactly  the  reverse  of  N"o.  11.    Ten  to  fifteen  times. 
"  13.  Bells  extended  above  the  head,  palmar  surfaces  looking 
forward,  bending  down  to  the  floor,  the  knees  remaining  ex- 


FiG.  130. 


Fig.  131. 


Fig.  132. 


Fig.  133. 


•tended,  and  return.    Five  to  fifteen  times  (Figs.  126  and  12Y). 
"  14.  Bells  downward  at  the  sides,  raising  and  dropping  the 
shoulders.     Ten  to  twenty  times  (Fig.  128), 


192 


OBTHOPEDIC  SUBGEBT. 


"  15.  Bells  do^vnward  at  the  sides,  flexing  the  spine  laterally, 
first  to  the  right  and  then  to  the  left.  Ten  to  twentv  times 
(Fig.  129). 

"  16.  Both  arms  are  extended  forward  to  abont  forty-five 
degrees  and  abducted  at  about  the  same  angle,  then  forcibly 
crossed  in  front  of  the  chest,  causing  the  pectoral  muscles  to  con- 


FiG.  134. 


Fig.  135. 


tract  vigorously,  the  elbows  and  wrists  being  fixed,  and  then 
back  to  the  original  position.  Five  to  twenty  times,  alternating 
the  right  and  left  hands  above  (Fig.  130). 

"  17.  Bells  at  the  sides,  palmar  surfaces  looking  forward. 
Extend  arms  backward  in  a  vertical  plane  as  forcibly  as  pos- 
sible, holding  them  rigid  in  the  fully  extended  position  for  a 
few  moments,  and  then  returning  the  bells  to  the  sides.  Five 
to  fifteen  times  (Figs.  131  and  132). 

"  18.  Bells  to  the  sides.  Raise  the  body  upon  the  toes  and 
sink  to  the  original  position.     Ten  to  twenty  times  (Fig.  133). 

"  19.  Same  position.  Raise  the  toes  as  far  as  possible  from 
the  floor,  the  body  remaining  erect.  Ten  to  twenty  times  (Fig 
134). 

"  20.  Same  position.  The  patient  squats,  abducting  the  knees 
and  resting  upon  the  toes,  the  heels  being  raised,  the  trunk  per- 
fectly erect,  then  resuming  first  position.  Five  to  twentv  times 
(Fig.  135). 

"  21.   Same  position.     Standing  upon  left  foot.     Flexing  the 


LATERAL  CUEVATUBE  OF  THE  SPINE. 


193 


right  thigli  to  a  right  angle  to  the  body,  extending  the  knee  and 
ankle  fully.     The  patient  squats  on  the  left  ham,  the  left  heel 


Fig.  136. 


Fig.  137. 


Fig.  138. 


Fig.  139. 


remaining  on  the  floor,  and  then  resumes  the  first  position.    Two 
to  five  times  (Fig.  136). 

"  22.  The  same  standing  upon  the  right  foot.     Two  to  five 
times. 
13 


194 


OBTHOPEDIC  SUBGEEY. 

Fig.  140. 


X 


X... 


"  23.  The  same  position.  Alternately  and  forcibly  flexing 
the  thighs  and  legs,  causing  the  knees  to  touch  the  shoulders. 
Ten  to  twenty  times  (Fig.  137). 


Fig.  141. 


Scoliosis  of  an  advanced  type  accompanied  by  dyspnoea  and  cyanosis.    (Teschner.) 


LATEEAL  CUEVATUBE  OF  THE  SPINE.  195 

"  24.  The  same  position  as  in  'No.  21,  extending  the  right 
lower  extremity,  the  right  bell  inside  the  thigh,  the  right  foot 
moved  in  a  circle  on  a  horizontal  plane  to  complete  extension 

Fig.  142. 


The  same  patient  swinging  30-pound  bell,  showing  the  muscular  development. 

(Teschner). 

backward,  and  resuming  the  first  position.  Two  to  five  times 
(Figs.  138  and  139). 

"  25.  The  same  as  JSTo.  24,  standing  upon  the  right  foot.  Two 
to  five  times. 

"  26.  The  patient  lying  supine  upon  the  floor,  the  lower 
extremities  fully  extended,  the  bells  resting  upon  the  chest,  then 
raising  the  trunk  to  the  sitting  position,  the  lower  extremities 


196 


OBTHOPEDIC  SUBGEEY. 


remaining  extended,  and  the  eves  being  fixed  npon  the  ceiling, 
and  returning  to  the  original  position,  touching  the  back  of  the 
head  only  on  the  floor;  thus  the  hjperextension  of  the  spine  is 
maintained.     Five  to  twenty  times  (Fig.  140)." 


Fig.  143. 


Fig.  144. 


The  patient  pushing  25pound  bells  ;     The  patient   pushing  25-pound  bells 
the   right   arm    up.      (Teschner.)  ■  the  left  arm  up.      (Teschner.) 

I  consider  these  floor  exercises  especially  useful,  and,  in  prac- 
tice, add  several  others  to  those  described  by  Teschner,  viz. : 

27.  The  patient  lying  as  in  Fig.  1-iO,  lifts  each  fully  extended 
leg  alternately  a  distance  of  about  two  feet  from  the  floor,  then 
lets  it  slowly  sink  to  its  original  position.     Ten  times. 

28.  Both  limbs  together.    Five  times. 


LATERAL  CURVATURE  OF  TEE  SPINE.  197 

29.  The  patient  lying  extended  in  the  prone  position,  places 
the  palms  of  the  hands  on  the  hips  and  "  looks  at  the  ceiling," 
overextends  the  spine  as  ninch  as  possible,  then  sinks  slowly  to 
the  original  position. 

30.  Each  leg  fully  extended  is  lifted  upward  alternately  as 
far  as  possible  (hyperextension  at  the  hips).     Ten  times. 

31.  Hyperextension  at  both  hips  simultaneously  if  possible. 
Five  times. 

"When  the  patient  has  become  proficient  in  these  exercises, 
they  should  be  done  at  home  every  morning  and  evening. 

"  The  Heavy  Wokk. — Bells,  weighing  from  five  to  eighty 
pounds  each,  and  steel  bars  and  bar-bells,  weighing  from  twenty- 
six  to  over  one  hundred  and  eleven  pounds,  are  used  in  different 
ways.  Bells  are  pushed  from  the  shoulders  above  the  head  alter- 
nately as  often  as  the  patient  is  able  (Figs.  143  and  144). 

"  The  patient  is  instructed  to  swing  a  heavy  bell  with  one 
hand  from  the  floor  above  the  head  and  down  again,  the  elbow 
and  the  wrist  being  fixed,  and  the  motion  repeated  as  often  as 
possible  in  a  systematic  manner;  then  with  the  other  hand  the 
same  number  of  times  and  later  with  both.  This  exerts  all  the 
extensor  muscles  from  the  toes  to  the  head  in  rapid  succession." 

(For  this  exercise  the  patient  stands  firmly,  with  the  legs 
astride  of  the  heavy  bell,  and  then,  bending  over,  he  seizes  it 
and  throws  the  extended  arm  upward  entirely  by  the  action  of 
the  back  muscles.  The  bell  is  poised  for  a  moment  above  the 
head,  and  it  is  then  swung  downward,  carrying  the  extended 
arm  between  and  behind  the  legs.) 

"  When  a  heavy  bell  is  pushed  or  swung  above  the  head  on 
the  side  opposite  the  scoliosis,  the  action  of  the  back  muscles,  to 
sustain  the  weight  and  equilibrium,  is  such  as  to  cause  the 
curved  spine  to  approximate  a  straight  line  (Fig.  144).  A 
similar  result  is  produced  when  a  heavy  weight  is  held  by  the 
side  of  the  erect  body  on  the  scoliotic  side,  the  arm  being  at  full 
length. 

"  When  a  heavy  bar  is  raised  above  the  head  with  both  hands 
the  patient  must  fix  the  eyes  upon  the  middle  of  the  bar  to  main- 
tain an  equilibrium.  This  necessitates  the  bending  of  the  head 
backward,  the  straightening  and  hyperextending  of  the  spine^ 
and  consequently  correcting  a  faulty  position  with  a  weight 
superimposed.  The  heavier  the  weight  put  above  the  head, 
whether  with  one  hand  or  with  two,  the  more  the  patient  must 
exert  himself  or  herself  to  attain  and  maintain  a  correct  or  an 


198 


ORTHOPEDIC  SUBGEEY. 


improved  attitude  in  order  to  sustain  the  equilibrium.  (By  an 
improved  attitude  I  mean  the  greatest  amount  of  correction  of 
the  deviation  of  the  spine  that  the  fixation  of  a  deformity  will 
alloM^.)  Hence,  the  greater  the  weight,  the  more  forcible  the 
actions  of  the  muscles  become,  and  the  greater  the  temporary 
reduction  of  a  deformity.  It  is  by  means  of  frequent  and  forci- 
ble temporary  reductions  of  deformities,  by  voluntary  muscular 
action,  that  we  can  hope  to  improve,  and  do  improve,  those  cases 
which  are  amenable  to  any  form  of  active  treatment. 

"  When  a  patient,  lying  supine  upon  the  floor,  raises  a  heavy 
bar  above  the  head  so  that  the  arms  are  perpendicular  to  the 
floor,  the  weight  of  the  bar,  the  position  and  weight  of  the  body, 
and  the  action  of  the  muscles  tend  to  broaden  the  entire  back 
and  shoulders,  and  a  slow  downward  movement  tends  to  widen 
the  entire  chest,  and  most  markedly  at  the  shoulders.  The  fre- 
quent repetition  of  the  upward  and  dovniward  movements  plays 
an  important  part  in  the  rapid  development  of  the  chest  and 
back.  Pushing  the  bells  above  the  head,  swinging  them  with 
each  hand  separately  and  with  both  hands  together,  raising  a 
bar  above  the  head,  standing  and  lying  down,  and  the  exercises 
before  enumerated,  constitute  one  day's  work. 

Eecord   of   the  Work   Performed   by  a   Girl  Fourteen   Years   of 
Age   (Teschner). 


Date 

Regu- 
lar ex- 
ercises. 

Bells. 

Pushing 

two  10-lb. 

bells. 

Swinging 
with  each 
hand  one 
15-lb.  bell, 
right  to  left. 

Swinging 
with  both 
hands  two 
1.5-lb.  bells. 

Pushing 

two  20-lb. 

bells. 

50-lb.  bar  above  the 
head. 

1895. 

Standing, 

Lying 
down. 

April  6 
"      9 
"     11 

"     13 

"     16 
"     18 

"     20 
"     25 
"     27 
"     30 
May    2 

"      4 
"      7 
"     14 
"     16 

3  lbs. 

100 

150 

2  15  lb.  bells 

50 

54 

60 

70 

90 
100 
110 
120 

140 
150 
160 
170 

10-10 

2.5-25 
1  20-lb.  bell 

25-25 

30-30 

35-35 
1  25-lb.  bell 

20-20 

22-22 

35-35 

50-50 

60-60 
1  30-1  b.  bell 

20-20 

25-25 

27-27 

30-30 

5 
15 

25 
35 
40 
2  20-lb.  bells 
20 
25 
30 
35 
36 

40 
45 
50 
55 

10 

12 
18 
20 

30 
33 
50 
60 
70 
2  2o-lb.  bells 
25 
30 
34 
40 

Instructed. 
2 

5 

7 
7 

10 
15 
17 
20 
20 
64-lb.  bar 

5 

7 

9 
10 

Instructed. 
5 

10 
12 
15 

15 
16 
20 
22 
25 
64-lb.  bar 
10 
12 
13 
14 

"As  the  amount  of  work  performed  by  a  patient  depends 
upon  the  last  previous  record  of  that  patient,  that  record  must 
be  improved  upon  at  each  succeeding  visit,  unless  there  be  a  good 
reason  to  the  contrary.      Most  patients  can  well   stand  three 


LATEEAL  CUEFATUBE  OF  THE  SPINE.  199 

treatments  a  week  (vide  table).  In  mild,  habitual  cases  im- 
provement in  deportment  is  noticed  by  the  patient's  relatives 
and  friends  and  by  the  patients  themselves  within  the  first  two 
weeks.  In  these  cases  two  months'  treatment  usually  suffices  to 
effect  a  '  complete '  cure.  In  the  more  severe  cases  such  rapid 
results  cannot  be  expected,  but  a  certain  appreciable  improve- 
ment is  effected,  and  the  amount  of  improvement  depends  upon 
the  persistent  continuance  of  the  treatment.  When  there  is 
fixed  rotation  of  long  standing,  with  bony  and  ligamentous 
changes,  the  prospect  is  not  as  good ;  but  even  in  those  cases 
considerable  improvement  will  be  evident." 

"  Patients  are  not  permitted  to  wear  supports  of  any  kind,  not 
even  corsets.  They  should  not  exercise  until  at  least  two  hours 
after  a  meal,  nor  when  menstruating.  The  general  health  is 
improved  by  the  exercises ;  the  patients  gain  in  height  and 
weight.  The  girth  and  breadth  measurements,  chest  depth, 
strength  tests,  and  lung  capacity  are  generally  increased,  and 
the  depth  of  the  abdomen  is  usually  decreased.  In  some  cases, 
especially  those  of  undersized  patients,  the  increase  in  height  is 
very  rapid,  and  it  is  certainly  more  than  the  increase  by  ordi- 
nary growth.  There  were  marked  cases  of  flat  foot  which  were 
benefited.  The  flat  feet  became  shorter  through  the  exercises  by 
the  increase  in  depth  of  the  inner  arches." 

This  system  of  exercises  combines  the  forcible  correction  of 
deformity  and  the  overcoming  of  restriction  of  normal  motion  by 
means  of  the  "  heavy  work  "  with  muscle  building.  It  has  the 
merit  also  of  making  an  immediate  mental  impression  upon  the 
patient  which  no  other  system  can  make ;  for  if  the  patient  does 
not  ."  strain  every  nerve "  he  must  certainly  exercise  every 
muscle  to  preserve  the  equilibrium  while  supporting  the  heavy 
weights,  and  this  mental  impression  is,  undoubtedly,  one  of  the 
important  elements  in  successful  treatment. 

The  system  has  the  disadvantage,  if  disadvantage  it  may  be 
called,  of  making  class  work  impossible,  for  the  patient  must  be 
under  constant  supervision,  not  only  that  he  may  be  urged  to 
the  limit  of  his  capacity,  but  that  overstrain  may  be  avoided 
as  well. 

It  might  appear  from  the  description  that  the  danger  of  over- 
work is  great,  but  in  a  long  series  of  cases,  some  of  which  were 
complicated  by  defects  of  the  heart  and  lungs,  no  unfavorable 
symptoms  have  been  observed  by  Teschner.  The  system  is, 
however,  one  that  can  only  be  practised  by  a  physician. 


200 


OBTHOPEDIC  SURGERY. 


Anotlier  system  of  exercises,  modified  somewhat  from  the 
Swedish  system,  more  suitable  for  class  work  is  that  followed  at 
the  Hos]3ital  for  Ruptured  and   Crippled.     Dr.   Truslow  has 


Fig.  145. 


liPdiisr" 


mmm 

{.«'',.'»3fj 


Typical   lateral   curvature.     Right  dorsal.     Left  lumbar. 


LATEBAL  CUEVATVEE  OF  THE  SPINE.  201 

outlined  for  me  some  of  the  more  important  exercises,  and 
illustrated  them  with  the  photographs  that  are  reproduced  here. 

The  objects  of  the  treatment  are:  (1)  To  overcome  the 
patient's  faulty  habits  of  posture  by  the  repeated  pur|3oseful 
assumption  of  proper  postures  ;  in  other  words,  to  counteract  the 
defonnity  habit  by  training  the  mental  and  muscular  percep- 
tion of  symmetry.  (2)  To  stimulate  and  to  strengthen  the 
weakened  muscles,  particularly  those  muscular  groups  that  are 
especially  concerned  in  overcoming  the  deformities,  and  which, 
for  the  present  purpose,  may  be  considered  as  weak. 

For  convenience  of  description  the  exercises  are  divided  into 
two  classes:  (1)  self-correction;   (2)  muscle  building. 

Exercises  in  Self-correction. — The  iirst  exercises  (a  and  h)  in 
self-correction  are  for  "the  purpose  of  overcoming  the  antero- 
posterior deformities  that  usually  accompany  lateral  deviation 
of  the  spine. 

(a)  Head  Bending  Backward. — In  this  exercise  the  chin  is 
not  tilted  upward,  but,  the  head  being  held  level,  the  neck  is 
drawn  directly  backward  until  the  cervical  and  upper  part  of 
the  dorsal  segments  of  the  spine  are  completely  extended.  Thus, 
by  increasing  the  distance  between  the  points  of  attachment  of 
the  sternomastoids  and  the  scaleni,  strong  traction  is  made  upon 
these  muscles  with  the  effect  of  elevating  the  upper  part  of  the 
thorax — an  important  feature  in  the  exercise. 

(&)  Trunk  Bending  Forward  and  Trunk  Raising. — The 
patient  stands  in  the  erect  posture  with  the  spine  extended  and 
the  chest  expanded  as  in  the  previous  exercise.  The  trunk  is 
then  bent  forward  (similar  to  Fig.  150),  the  only  motion  being 
at  the  hip-joints.  The  trunk  is  then  raised  again  to  the  former 
position,  care  being  taken  to  keep  the  hips  farther  back  than  the 
chest.  In  both  flexion  and  extension  the  spine  must  be  rigidly 
held  in  the  corrected  attitude,  and  there  must  be  no  motion  at 
the  knees.  There  is,  of  course,  a  movement  corresponding  to 
extension  at  the  ankle-joints  when  the  legs  and  buttocks  are 
thrown  backward  to  compensate  for  the  forward  bending  of  the 
body.  The  object  of  this  exercise  is  to  train  the  patient  to  keep 
the  hips  back  and  the  chest  forward. 

The  other  exercises  in  self-correction  are  for  the  purpose  of 
overcoming  lateral  deviation  of  the  spine,  the  right  dorsal,  left 
lumbar  curve  being  taken  as  the  type  (Fig.  145). 

This  series  is  arranged  in  a  progression,  and  each  one  must  be 
learned  before  the  next  in  order  is  attempted. 


202 


OBTHOPEDIC  SUBGEBY. 


(c)  Left  ITeck  Fiem. — The  left  hand  is  placed  behind  the 
neck,  the  left  shoulder  is  raised,  and  the  left  elbow  is  held  well 
back.  This  posture  impresses  upon  the  patient  the  necessity  of 
approximating  the  left  shoulder  and  the  neck  (Fig.  146). 

Fig.  146. 


Left   neck   firm. 

(d)  Body  Inclination  to  the  Left. — This  is  a  most  im- 
portant posture  ;  it  is  intended  to  correct  mechanically  the  faulty 
inclination  to  the  right  and  to  overcome  the  upper  curve  by  trac- 
tion on  its  concavity.  The  patient  holding  the  arm  in  the  first 
position  is  instructed  to  stretch  well  out  with  the  left  elbow, 
rotating  upward  and  abducting  the  left  scapula  as  much  as  pos- 
sible.    This  puts  upon  the  stretch  the  rhomboidei  and  the  lower 


LATEEAL  CUEVATUME  OF  THE  SPINE. 


203 


half  of  the  trapezius  of  the  left  side,  thus  making  strong  trac- 
tion upon  their  points  of  attachment  in  the  dorsal  concavity.  At 
the  same  time  the  patient  is  directed  to  sway  the  pelvis  to  the 
right.  This  usually  requires  assistance  at  first,  for  it  brings 
into  action  certain  deep  back  muscles,  over  which  one  has  ordi- 
narily but  little  control.     The  shoulders  must  be  kept  level  and 

Fig.  147. 


~'*3*fl*lfe<-. 


Body  inclination  to  tlie  left. 


the  proper  relation  of  the  head  and  neck  to  the  left  shoulder 
must  not  be  disturbed  in  this  forced  stretch  to  the  left 
(Fig.  147). 

(e)  Chest  Pressing  with  the  Right  Hand. — The  patient 


204 


OETHOPEDIC    SUEEGPiY. 


holding  the  left  arm  in  the  first  position  presses  the  right  hand 
firmly  against  the  dorsal  convexity.  This  posture  may  be  em- 
ployed to  advantage  if  there  is  a  long  right  dorsal  curve,  when 
it  is  an  efiicient  aid  to  the  left-sided  pull  of  the  tvro  former 
exercises. 

(/)  KiGHT  Xeck  FiE:\r. — The  right  hand  is  placed  behind 
the  neck,  v^^ithout,  however,   distttrbing  the  improved  position 

Fig.  1-iS. 


Right    neck    firm. 


induced  by  the  first  exercises.  AYith  both  hands  placed  behind 
the  head,  the  arms  being  in  a  symmetrical  position,  there  is 
better  mechanical  fixation  of  the  head,  neck,  and  upper  part  of 
the  trunk  during  the  next  exercise  (Fig.  148). 

(g)  Left  Hip  Twisting  Backward. — In  posture  (d)  the 
pelvis  was  swayed  slightly  to  the  right ;  it  is  now  twisted  slightly 
backward  on  the  left  side  to  overcome  the  twist  in  the  lumbar 


LATERAL  dUEVATUBE  OF  THE  SPINE.  205 

Fig.  149. 


Left  oblique  stride  standing. 

spine  which  usually  throws  this  side  of  the  pelvis  somewhat  for- 
ward. This  correcting  motion  should  be  carried  out  in  the 
lower  dorsal  and  lumbar  segments,  and  it  should  not  affect  the 
attitude  of  the  remainder  of  the  trunk. 


206 


OBTEOPEDIC  SUBGEBY. 


(h)  Left  Oblique  Stride  Staxdixg. — The  pelvic  twist  and 
right-sided  sway  being  rigidly  maintained,  the  left  foot  is  placed 
about  two  foot-lengths  forward  and  a  little  outward.     Upon  this 


Fig.  150. 


Trunk  bending  forward. 


log  the  greater  part  of  the  weight  of  the  body  is  now  supported. 
This  allows  a  slight  doT\mward  tilt  of  the  pelvis  to  the  right,  and 
lessens  the  left  lumbar  convexity  (Fig.  149).  The  positions, 
attained  by  the  progressive  exercises  to  this  point,  being  main- 
tained, the  patient  continues  with — 


LATERAL  CUEVATUBE  OF  THE  SPINE.  207 

(i)  Trunk  Bending  Fokwaed. — In  this  posture,  motion 
takes  place  in  the  hip-joints  only,  as  in  the  first  exercise.  This 
exercise  further  emphasizes  the  symmetrical  position  of  the 
head  and  neck,  the  left-sided  inclination  of  the  upper  half  of 
the  trunk,  the  right-sided  inclination  of  the  lower  half,  the  twist 
and  downward  tilt  of  the  pelvis  (Fig.  150).  The  return  to  the 
improved  standing  position  should  be  made  in  this  order:  (1) 
trunk  raising;  (2)  replacement  of  the  left  foot;  (3)  return  of 
both  arms  to  the  sides.  This  is  done  slowly  and  carefully  by 
the  patient,  who  attempts  to  maintain  the  improved  posture. 

The  postures  constitute  a  progression  which  cannot  be  learned 
in  less  than  seven  treatments  ;  often  much  more  time  is  required. 
As  each  part  is  learned  it  should  be  practised  at  home  until  the 
next  treatment,  when  a  new  posture  is  added,  if  it  appears  that 
progress  can  be  made. 

These  successive  postures  are  in  reality  exercises  in  that  it 
requires  constant  muscular  effort  to  retain  them,  but  they  are 
not  exercises  in  the  sense  of  repeated  alternations  of  position. 
The  series  is  simply  an  elaboration  of  what  is  called  the  keynote 
posture.  The  raising  of  the  left  elbow,  for  example,  makes  it 
easier  for  the  patient  to  overcome  the  distortion  of  the  upper 
part  of  the  spine ;  it  also  instructs  him  in  the  manner  of  holding 
the  spine  in  the  improved  position  after  the  arm  is  placed  by 
the  side. 

The  same  is  true  of  all  the  postures ;  each  one  suggests  and 
makes  correction  easier,  and  after  sufficient  practice  the  patient 
should  be  able  to  assume  the  correct  position  without  placing 
the  arm  or  the  leg  in  the  preliminary  attitude.  Thus  the  suc- 
cessive postures  are,  as  it  were,  letters,  which,  placed  together 
one  by  one,  make  a  complete  word,  or  the  best  possible  position 
that  the  patient  can  assume.  At  first  the  patient  must  use  the 
letters  and  slowly  spellout  the  corrected  attitude,  but  after  the 
muscles  have  been  educated  by  the  repeated  assumption  of  each 
posture,  and  when  the  perception  of  symmetry  has  been  ac- 
quired, the  corrected  attitude  may  be  assumed  at  will.  Finally, 
the  improved  posture  will  be  instinctively  retained,  and  will 
become  habitual. 

Muscle  Building  Exercises.. — In  the  treatment  of  lateral  curva- 
ture one  aims  to  strengthen : 

1.  The  posterior  cervical  muscles. 

2.  The  dorsal  and  lumbar  muscles. 

3.  The  muscles  of  vertebroscapular  attachment. 


208 


OFTROPEDIC  SUBGEBY. 


•i.   The  abdominal  muscles. 

5.  The  thigh  and  leg  muscles. 

6.  The  chest  expanding  muscles. 

Fig.  151. 


"  Opposite  bend  standing,"  trunk  raising,  resisted. 

The  following  exercises  have  been  selected  as  best  adapted 
for  this  purpose.  Each  one  should  be  performed  five  or  more 
times  according  to  the  strength  of  the  patient. 


LATERAL  CVBVATUBE  OF  THE  SPINE. 

Fig.  152. 


209 


14 


Prone  lying,   "  diving. 


210  OBTHOPEDIC  SUBGEBY. 

(a)  OprosiTE  Standing,  Head  Bending  Backward,  Re- 
sisted.— The  patient  stands  before  a  wall  or  a  shoiilder-higli 
horizontal  bar,  on  which  the  hands  are  placed  with  the  arms 
extended.  The  head  is  bent  forward,  and  is  then  forced  back- 
ward, the  latter  movement  being  resisted  by  the  hand  of  the  sur- 
geon. This  exercise  is  designed  to  strengthen  the  posterior 
cervical  muscles. 

(h)  Opposite  Bend  Standing,  Trunk  Raising,  Resisted. 
— The  patient  stands  with  the  upper  part  of  the  thighs  in  con- 
tact with  a  table  or  horizontal  bar.  The  hands  are  placed  behind 
the  neck  and  the  body  is  bent  forward  on  the  hip-joints  as  in 
the  first  exercise.  The  surgeon,  standing  behind,  places  his 
right  hand  over  the  posterior  dorsal  prominence  and  his  left  over 
the  lumbar  projection.  The  patient  then  raises  the  trunk  to  the 
erect  position  against  the  combined  resistance  (Fig.  151).  With 
a  little  practice  the  surgeon  leams  to  give  an  outward  twisting 
motion  to  his  hands  while  resisting,  which  tends  to  untwist  the 
spinal  rotations.  When  the  dorsal  rotation  to  the  right  is 
marked  this  untwisting  may  be  facilitated  by  encircling  the 
patient's  chest  with  the  left  hand,  while  with  the  right,  strong 
forward  and  outward  pressure  is  made  as  the  patient  raises  the 
body.  This  exercise  is  for  the  purpose  of  developing  the  muscles 
of  the  erector  spinee  group. 

(c)  Prone  Lying,  Head  and  Shoulder  Raising  "  the 
Seal." — The  patient  lies  upon  a  table  or  upon  the  floor,  and 
raises  the  head  and  chest — "  looks  at  the  ceiling."  Progression 
is  made  in^the  increased  leverage  of  arm-weight  transference. 

1.  With  the  hands  on  the  backs  of  the  thighs. 

2.  With  the  left  hand  behind  the  neck  and  the  right  hand 
on  the  back  of  the  thigh, 

3.  With  both  hands  behind  the  neck,  and  with  the  elbows  well 
out  and  back. 

4.  "  Swimming."  The  arm  motions  of  swimming,  in  three 
counts.  This  exercise  is  to  strengthen  the  muscles  of  the  back 
from  the  head  to  the  pelvis. 

(d)  Prone  Lying,  "  Diving." — The  patient  lies  upon  a  table 
the  trunk  and  pelvis  projecting  beyond  its  edge,  the  limbs  being 
fixed  by  a  strap  or  the  weight  of  another  person.  The  body 
is  then  bent  do"\vnward  and  is  raised  again  to  the  horizontal 
position  (Fig.  152).  In  this  exercise  assistance  will  be  required 
at  first.  Progression  is  made  by  transference  of  arm  weights, 
as  in  the  former  exercise,  thus: 

1.  AYith  the  hands  on  the  hips. 


LATERAL  CUBVATUEE  OF  THE  SPINE.  211 

2.  With  the  amis  stretched  out  at  right  angles  to  the  body. 

3.  With  the  hands  behind  the  neck. 

4.  With  the  arms  extended  in  the  line  of  the  body. 

This  exercise  is  for  the  purpose  of  strengthening  all  the 
muscles  of  the  back. 

(e)  Peone  Lying,  Leg  Raising. — The  patient,  lying  in  the 
prone  posture  upon  the  floor  or  table,  lifts  the  limbs  (overex- 
tends)  alternately,  the  raised  leg  held  perfectly  straight.  When 
the  left  thigh  is  extended,  as  much  as  the  iliofemoral  ligament 
will  allow,  the  left  side  of  the  pelvis  is  tilted  upward  also,  thus 
untwisting  the  lumbar  spine.  Progression  in  this  exercise  is 
made  as  follows : 

1.  Alternate  leg  raising,  unresisted. 

2.  Alternate  leg  raising,  resisted. 

3.  The  leg  motions  of  swimming  in  three  counts. 

In  this  exercise  the  entire  lower  extremities  must  project  be- 
yond the  supporting  table.  The  exercises  are  for  the  purpose 
of  strengthening  the  lumbar  muscles  and  the  extensors  of  the 
thigh. 

(/)  Opposite  Sitting,  Backwaed  Bending  of  the  Teunk. 
— The  patient  is  seated  upon  a  bench,  and  the  feet  are  fastened 
to  the  floor.  The  trunk  being  held  in  a  position  of  complete 
extension,  is  bent  slowly  backward,  motion  being  at  the  hip- 
joint  only.     Progression. 

1.  With  the  hands  behind  the  hips. 

2.  With  the  left  hand  behind  the  neck,  the  right  hand  on 

the  hii3. 

3.  With  both  hands  behind  the  neck. 

4.  With  both  arms  extended  upward. 

At  first  the  body  is  bent  backward  about  forty-five  degrees^ 
later  until  the  head  touches  the  floor.  This  exercise  is  to- 
strengthen  the  abdominal  muscles. 

(g)  The  Hoeizontal  Bae.  "Pull-ups." — The  patient 
hangs  by  the  hands  and  is  assisted  to  "  chin  the  bar."  The  body 
is  then  allowed  to  sink  slowly  back  into  the  former  position,  the 
elbows  are  held  well  back,  and  the  jDatient  is  instructed  to  bear 
as  much  of  the  weight  as  is  possible  with  the  left  arm  and 
shoulder.  This  exercise  corrects  the  dorsal  curve  by  means  of 
muscular  activity,  and  the  lumbar  curve  by  the  weight  of  the 
suspended  pelvis  and  limbs.  The  muscles  used  are  those  with 
vertebroscapula  attachment. 

(h)    Left  Leg   Standing,   Pelvis   Tilting. — The  patient 


212 


OBTHOPEDIC  SUEGEEY. 
Fig.  153. 


Lateral  curvature. 
Fig.  154. 


The  same  patient,  showing  fixed  rotation  to  the  right  in  the  thoracic  region. 
(See  Figs.  I.j.j  and  l.'iii.  illustrating  a  simple  correc-tive  exercise  that  may  be 
carried  out  by   the   patient.) 


LATEBAL  CUBVATUEE  OF  THE  SPINE. 
Fig.  155. 


213 


The  patient  shown  in  Figs.  154  and  155  inclines  the  body  to  the  right,  pressing 
the   projecting  ribs   in   with  the   right  hand.      (See  Fig.    152.) 


Fig.  156. 


In  the  posture  shown  in  Fig.   154,  the  patient  inclines  the  body  forward.     The 
correction  is  illustrated  by  comparison  with  Fig.  156  in  the  same  position. 


214  OBTHOPEDIC  SURGEBY. 

stands  upon  the  edge  of  a  bench,  supporting  the  weight  on  the 
left  leg,  the  right  leg  being  suspended  beyond  the  side  of  the 
bench.  While  the  head  and  trunk  are  kept  in  the  corrected 
position,  the  pelvis  is  made  to  tilt  sharply  downward  on  the 
right,  by  lowering  the  right  leg,  while  the  left  is  kept  perfectly 
stiff.     This  has  the  effect  of  straightening  the  lumbar  curve. 

(i)  Left  Leg  "  Hopping." — Both  hands  are  placed  behind 
the  neck  and  the  weight  is  supported  entirely  upon  the  ball  of 
the  left  foot.  In  this  attitude  the  patient  hops  ten  or  more 
times.  This  exercise,  like  the  last,  tends  to  straighten  the  spine 
and  to  strengthen  the  muscles  of  the  left  leg,  which  are  often 
somewhat  weakened  from  disuse. 

(j)  Kespiratoky,  Half  Reclining,  Arm  Extensions  and 
Flexions,  Resisted. — The  patient  sits  in  a  chair  with  an 
inclined  back,  or  lies  upon  a  low  table  with  hard  pillows  under 
the  mid-dorsal  region,  so  that  the  upper  dorsal  and  cervical 
segments  of  the  spine  must  be  overextended.  The  arms  are 
stretched  upward^  and  backward,  and  the  hands  are  grasped  by 
the  surgeon,  who  stands  behind  and  resists  the  patient's  down- 
ward pull.  With  the  upward  stretch  of  the  arms  and  pull  by 
the  surgeon  the  patient  inhales  forcibly.  With  the  downward 
pull  against  resistance  the  patient  exhales  forcibly.  This  ex- 
ercise is  made  in  the  rhythm  of  slow  breathing. 

When  the  patient  has  been  thoroughly  instructed  in  self- 
correction  and  in  the  exercises  for  muscle  building,  general 
gymnastics  for  systematic  motor  training  may  be  given  effec- 
tively to  groups  of  fifteen  or  twenty  puj)ils. 

The  exercises  illustrated  on  pages  186  to  193  will  serve  this 
purpose  satisfactorily. 

These  two  systems  of  treatment  by  gymnastics  have  been 
selected  as  the  most  practicable  of  the  many  that  have  been 
devised.  It  may  be  stated  that  any  treatment  that  makes  the 
spine  more  flexible,  that  overcomes  faulty  attitudes,  and  that 
strengthens  the  muscles,  must  be  of  service  to  the  patient,  the 
degree  of  benefit  corresponding  to  the  persistence  and  energy  of 
the  pupil  and  the  instructor  rather  than  to  any  particular  theory 
on  which  such  treatment  is  based.  The  rotation  of  the  vertebral 
bodies  is  increased  by  forward  bending  of  the  trunk,  and,  as  this 
is  the  more  important  element  of  lateral  curvature,  it  is  evident 
that  extension  or  overextension  of  the  spine,  combined  with 
lateral  twisting  in  such  a  manner  as  to  reverse  the  habitual 


LATERAL  CUBVATUBE  OF  THE  SPINE.  215 

inclination,  will  most  directly  lessen  or  correct  the  distortion. 
Exercises  of  this  character  are  far  more  effective  than  are 
elaborate  systems  of  general  gymnastics  (Figs.  155  and  156). 

Corrective  Treatment  Combined  with  Support. — It  should  be  evi- 
dent that  treatment  by  gymnastic  exercises,  during  which  the 
deformity  is  but  partly  corrected  and  after  which  it  is  per- 
mitted to  recur,  cannot  be  curative.  From  this  treatment  one 
may  hope  for  such  improvement  in  the  general  condition,  in  the 
muscular  strength  and  in  the  ability  to  hold  the  body  at  will  in 
better  position  as  will  check  the  progress  of  the  deformity  and 
mitigate  or.  conceal  its  effects. 

In  cases  therefore  of  resistant  deformity,  or  when  for  any 
reason,  simple  gymnastic  treatment  is  unsatisfactory,  the  follow- 
ing method  of  forcible  methodical  correction  combined  with  sup-  ^ 
port  should  be  employed. 

The  plaster  corset  is  the  most  practicable  support  because  it 
may  be  applied  directly  by  the  one  who  conducts  the  treatment 
and  thus  it  may  be  modified  and  renewed  at  frequent  intervals. 

It  should  be  applied  in  the  upright  attitude  as  described 
under  Pott's  disease.  By  suspension  the  normal  relation  of  the 
trunk  to  the  pelvis  may  be  restored  in'  great  degree  and  the 
direct  deformity  in  part  reduced. 

The  corset  should  press  upon  the  projecting  ribs,  but  not  upon 
the  flattened  part  of  the  trunk,  depressions  therefore  should  be 
filled  by  insertions  of  cotton  beneath  the  shirt.  If  the  patient 
is  a  female,  pads  of  cotton  should  be  placed  below  and  in  front 
of  the  breasts  to  prevent  pressure.  A  plaster  jacket  is  applied 
in  the  usual  manner,  the  deformity  being  further  corrected  by 
pressure  with  the  hands  during  the  hardening  stage.  It  is  then 
removed  and  is  bound  and  fitted  with  hooks  for  lacing. 

The  patient  is  provided  with  an  apparatus  for  self  suspension 
so  that  the  corset  may  be  removed  and  adjusted  in  the  original 
position. 

The  active  treatment  is  conducted  somewhat  as  follows:  The 
patient  is  placed  face  downward  on  a  narrow  table,  in  the 
absence  of  assistance  clasping  it  with  the  arms  to  fix  the  thorax. 
One  then  attempts  to  reduce  and  if  possible  to  overcorrect  the 
deformity  by  hyperextension,  and  by  lateral  flexion  of  the  trunk. 
Thus,  if  the  primary  lumbar  curvature  is  to  the  left,  the  opera- 
tor standing  on  this  side  of  the  table  and  with  the  left  hand 


216 


OBTHOPEDIC  SUBGEBY. 


pressing  downward  on  the  convexity,  with  the  other  lifts  the 
right  thigh  of  the  patient,  hyperextends  it  and  draws  it  upward 
and  toward  the  left,  lifting  and  turning  the  pelvis  in  a  manner 
to  untwist  the  spine  (Fig.  157). 

This  movement  is  carried  out  over  and  over  again  in  the 
"  pump  handle "  manner,  the  patient  assisting  and  eventually 
gaining  the  ability  to  throw  the  limb  backward  and  to  the  side 


Correction   of  a  left  lumbar  rotation  bv  natural   leverage. 


without  assistance.  The  dorsal  curvature  is  corrected  in  the 
same  manner  by  passing  the  arm  beneath  the  thorax  of  the 
patient,  hyperextending  the  trunk  and  at  the  same  time  rotating 
it  in  a  manner  to  overcome  the  deformity.  The  manipulation, 
lasting  about  twenty  minutes,  should  be  repeated  at  least  twice 
daily;  the  corset  is  then  applied  and  it  may  be  worn  with  ad- 
vantage during  the  night  (Fig.  159). 

As  the  spine  becomes  more  flexible  so  that  it  may  be  still 
further  corrected,  new  corsets  are  applied.  During  the  day  self 
suspension  at  intervals  is  of  service  and  the  patient  should  from 
time. to  time  assume  the  key-note  posture,  endeavoring  to  correct 
the  deformity  beyond  the  degree  enforced  by  the  corset. 
Massage  of  the  muscles  of  the  trunk  and  self  correction  exercises 
are  useful  in  supplemental  treatment. 


LATEBAL  CUBVATUBE  OF  THE  SPINE. 

Fig.  158. 


217 


Correction    of    n.    left    lumbar    curvature    by    natural    leverage    illustrating    the 
application  of  greater  force. 

Fig.  159. 


<  Oi  iiri  i(jn  of  a  left  dorsal  curvature  by  natural  leverage. 

By  this  method  a  continuous  and  satisfactory  improvement  is 
usually  apparent.  Eventually  the  plaster  support  may  be  re- 
placed by  an  ordinary  stiffened  corset. 


218 


OBTHOFEDIC  SUBGEBY. 


Fig.  160. 


In  this  method  of  treatment  the  plaster  corset  serves  only  as 
a  retention  brace,  the  correction  of  the  deformity  being  ac- 
complished by  the  manipulation  and  exercises.  In  other  in- 
stances when  the  corrective  treatment  is  impracticable,  as  in  the 
hospital  class,  a  fixed  jacket  may  be  employed,  more  corrective 
force  being  used  in  its  application. 

For  example  the  patient  may  be  suspended  in  the  prone 
posture  on  a  strip  of  cotton  cloth  (the  hammock  method).  As 
this  sinks  under  the  weight  the  trunk  falls  into  the  attitude  of 

overextension,  which  is  that 
most  favorable  for  the  untwist- 
ing of  the  rotated  spine.  When 
the  deformity  is  marked,  the 
body  may  be  suspended  in  the 
lateral  attitude  by  means  of 
a  sling  of  cotton  cloth  passed 
about  the  prominent  ribs ;  thus 
the  weight  of  the  body  acts 
as  a  correcting  force  during 
the  application  of  the  corset. 

In  using  such  corrective 
force  one  endeavors,  if  possi- 
ble, to  overcorrect  the  habitual 
deformity  and  the  less  marked 
changes  in  the  anteroposterior 
contour  as  well.  For  example, 
if  the  lumbar  region  is  flat 
one  attempts  to  reproduce  the 
normal  lordosis,  and  if  the 
body  is  habitually  inclined  in 
one  direction  one  endeavors 
to  sway  it  to  the  opposite  side, 
and  to  efface  the  so-called  high 
hip.  These  j  ackets  are  chang-ed 
at  frequent  intervals.  They 
are   particularly   indicated   in 

Forcible  correction  by  means  of  the  deformity  of  the  paralytic  Or 
modified     Hoffa     appliance.        (Bradford      i        i  •,•  '.  •  J^  ,i^ 

and  Bracicett.)  rhachitic  type   lu  young  sub- 

jects. 
A  better  form  of  fixed  support  is  the  jacket  applied  after  the 
Calot  method  in  which  direct  pressure  is  made  by  means  of  pads 
over  the  convexitv  of  the  defonnitv,  a  "  window  "  having  been 


LATEEAL  CUBVATUBE  OF  THE  SPINE. 


219 


cut  out  on  the  opposite  side  to  permit  expansion.  In  treatment 
by  fixed  supports  in  which  pressure  is  exerted  on  the  deformity 
and  space  provided  for  correction,  the  respiratory  movements  of 
the  chest  are  an  aid  in  rectification.  Greater  corrective  force 
may  be  applied  by  machines  as  illustrated  in  Fig.  160,  the 
jacket  being  applied  to  include  the  pressure  pads. 

When  the  deformity  is  dependent  upon  irremediable  injury 
or  disease,  such,  for  example,  as  anterior  poliomyelitis  or  empy- 
ema, some  form  of  brace  must  be  employed  constantly  to  pre- 
vent excessive  lateral  deviation  of  the  trunk ;  and  in  cases  of 
fixed   deformity  in   older  subjects,   especially  if  the  patient's 


FiCx.  161. 


The  Knight  spinal  brace,  as  used  in  lateral  curvature.  A  leather  or  canvas 
band,  made  adjustable  by  lacings,  is  stretched  from  the  posterior  upright  to  the 
side  bar  on  the  side  of  the  dorsal  convexity. 

occupation  is  fatiguing,  a  support  may  be  indicated  to  relieve 
symptoms  of  discomfort  or  pain. 

SupjDort  is  employed  primarily  with  the  aim  of  preventing 
an  increase  of  deformity  and  to  relieve  symptoms  incidental  to 
the  deformity.  It  may  serve,  also,  in  some  degree  as  a  correc- 
tive apiDliance.  If  it  holds  the  spine  in  the  extended  position  or 
induces  lordosis,  it  may,  by  relieving  the  anterior  portion  of  the 
column  in  part  from  the  deforming  influence  of  superincumbent 
weight,  induce  or  permit  a  slight  lessening  of  the  rotation  of  the 
vertebral  bodies.  On  this  principle  a  light  steel  brace,  after  the 
Taylor  model,  may  be  as  effective  as  any  of  the  more  compli- 


220  OBTHOPEDIC  SUBGEBY. 

cated  apj)liances,  as  was  suggested  many  years  ago  by  Judson. 
Corsets  of  other  material  than  plaster,  for  example,  of  paper,  or 
of  aluminum,  as  suggested  by  Phelps,  may  be  employed  when 
the  deformity  is  fixed  and  when  no  change  in  the  position  or 
size  of  the  trunk  is  to  be  expected.  The  Knight  brace,  when 
carefully  adjusted,  appears  to  meet  the  requirements  fairly  well, 
and  when  less  support  is  needed  an  ordinary  corset  strengthened 
by  light  steels  may  be  sufficient.  Even  in  cases  of  this  character 
corrective  exercises  should  be  employed  with  the  aim  of  preserv- 
ing as  far  as  possible  the  flexibility  of  the  spine. 

Fig.  162. 


Congenital  scoliosis.     After  treatment  for  three  years  by  forcible  correction  and 
fixation  by  plaster  jackets.      Showing   the   disappearance   of  the   rotation. 


SUPPLEMENTAL  TREATMENT. 

The  Removal  of  Superincumbent  Weight. — The  removal  of  super- 
incumbent weight  by  the  assumption  of  the  reclining  posture 
whenever  the  patient  is  fatigued  is  an  important  adjunct  in  the 
treatment.  The  patient  should  lie,  preferably,  upon  a  hard 
support  in  the  supine  posture,  with  the  arms  extended  above 
the  head.  If  the  dorsal  kyphosis  is  exaggerated,  a  firm  cushion 
between  the  shoulders  or  under  the  projecting  ribs  will  aid  to 
expansion  of  the  chest  and  favor  the  correction  of  the  deformity. 

Self-suspension. — Self-suspension,  by  means  of  the  halter  and 
pulley,  is  of  service  in  overcoming  secondary  contractions  of  the 
tissues,  and  thus  it  aids  in  the  correction  of  deformity.  It  is 
often  efficacious,  also,  in  relieving  the  discomfort  that  is  some- 


LATERAL  CURVATURE  OF  THE  SPINE. 


221 


times  a  troublesome  symptom  when  the  distortion  is  extreme. 
While  the  patient  is  suspended  forcible  manual  correction  of  the 
deformity  may  be  applied  to  advantage. 


Fig.  163. 


Fig.  164. 


Self-suspension,  illustrating  the  effect  of  traction  in  lessening  deformity  induced 
by  paralysis.      (Gibney.)      In  such  cases  support  is  essential. 

Suspension  from  the  horizontal  bar  has  a  similar  effect, 
although  it  is  less  effective  than  when  the  traction  is  made  upon 
the^  entire  spine.  In  this  form  of  suspension  the  bar  should  be 
oblique  in  direction,  the  high  side  for  the  low  shoulder.     Thus, 


222  OBTHOPEDIC  SUEGEBY. 

a  passive  ''  keynote  "  is  induced  while  the  patient  is  suspended. 
Exercises  in  this  position,  for  example,  flexion,  extension,  and 
abduction  of  the  thighs,  swaying  the  trunk  from  side  to  side, 
"  chinning  "  the  bar,  and  the  like,  are  useful. 

Volkmann  Seat. — In  cases  of  primary  lumbar  curvature,  or 
when  the  secondary  curve  of  this  region  is  pronounced,  the  atti- 
tude may  be  improved  and  the  deformity  may  be  corrected  in 
part  by  seating  the  patient  on  an  inclined  plane,  the  high  side 
beneath  the  low  hip,  thus  lessening  the  convexity  of  the  curve. 

High  Shoe. — The  same  object  may  be  attained  in  the  erect 
posture  by  the  use  of  a  higher  heel,  or  heel  and  sole.  The  eleva- 
tion may  be  from  a  half-inch  to  an  inch  and  a  quarter,  the 
amount  being  regulated  by  its  effect  upon  the  contour  of  the 
trunk. 

Support  during  Recumbency. — If  a  corrective  corset  is  used  it 
may  be  worn  with  advantage  at  night — or  a  plaster  bed  cor- 
responding to  the  posterior  half  of  a  jacket  may  be  constructed. 
This  is  suitably  padded  and  is  fixed  to  cross  bars.  In  this  the 
patient  lies  at  night,  deformity  being  prevented  and  a  certain 
corrective  force  is  also  exerted.  This  support  according  to 
Jaeger  is  not  only  tolerable  but  is  more  comfortable  in  cases  of 
advanced  deformity  than  is  the  ordinary  bed. 

General  Treatment. — The  importance  of  improving  the  gen- 
eral condition  of  the  patient  by  regTilation  of  the  diet,  by  cold 
baths,  and  by  active  exercise  in  the  open  air  is  self-evident.  The 
strain  upon  the  back  should  be  lessened  by  providing  proper 
seats  and  by  limiting  the  time  passed  in  passive  attitudes,  and  by 
lessening,  as  far  as  possible,  the  restraint  of  the  clothing.  These 
precautions  are  of  almost  equal  importance  with  the  active 
treatment. 

The  Duration  of  Treatment. — The  duration  of  treatment  de- 
pends, of  course,  upon  the  character  of  the  deformity  and  upon 
its  causes.  In  the  ordinary  type  of  adolescent  scoliosis  the  dura- 
tion of  active  treatment  is  usually  from  three  to  six  months.  In 
this  time  the  muscles  may  be  so  strengthened  and  the  necessity 
for  constant  attention  to  the  attitudes  may  be  so  impressed  upon 
the  patient  that  the  simple  exercises  which  may  be  performed 
at  home  may  be  sufiicient.  In  such  exercises  the  most  important 
postures  are  those  which  hyperextend  the  spine.  The  constant 
effort  should  be  to  make  motion  in  one  direction  as  free  as  in 
another,  and  to  practice  postures  that  tend  to  reduce  deformity. 
In  all  cases  it  is  well,  if  possible,  to  keep  the  patient  under 
supervision  during  the  period  of  growth. 


CHAPTEE  IV. 

DEFOEMITIES  OF  THE  SPINE    (Continued).     DEFORMITIES 

OF  THE  CHEST.     THE  FUNCTIONAL  PATHOGENESIS 

OF  DEFORMITY. 


VARIATIONS   IN   THE   CONTOUR   OF    THE    SPINE. 

Oi^E  recognizes  a  certain  contour  of  the  spine  as  normal,  but 
there  are  variations  from  this  type  which,  within  certain  limits. 


Fig.  16.5. 


Fig.  166. 


^ 


The  hollow   round   back.      (Stafel.) 


The   round   back.      (Stafel.) 


can  hardly  be  classed  as  abnormal.     Two  of  these  have  been 
mentioned:  the  round  hack  (Fig.  166),  in  which  there  is  a  gen- 

223 


224  OBTHOPEDIC  SUEGEBY. 

eral  forward  droop  most  marked  at  the  shoulders,  and  the  hollow 
round  hack  (Fig.  165),  in  which  the  dorsal  kyphosis  and  the 
lumbar  lordosis  are  somewhat  exaggerated.  A  third  type  is  the 
flat  had'  (Fig.  93),  in  which  there  is  neither  a  lumbar  lordosis 
nor  a  dorsal  kyphosis.  In  the  marked  cases  there  is  an  actual 
prominence  in  the  lumbar  region,  while  the  scajDulse  project 
backward,  overhanging  the  flattened  dorsal  spine.  This  type  of 
back  is  the  result,  in  many  instances,  of  a  rhachitic  kyphosis 
which  was  most  prominent  in  the  lumbar  region,  and  it  often 
follows  a  primary  lateral  rotation  of  the  lumbar  vertebrse.  The 
flat  back  and  the  round  back  jDredispose  to  lateral  curvature. 
Deviations  from  the  normal  contour  of  the  spine  are  attended  by 
a  change  in  the  inclination  of  the  pelvis  and  in  the  relation  of 
the  support  of  the  limbs  and  trunk.  The  round  back  (Fig.  166) 
is  almost  always  indicative  of  weakness,  and  it  is  often  accom- 
panied by  other  j)ostural  deformities,  especially  often  by  weak 
feet. 

ANTEROPOSTERIOR  DEFORMITIES  OF  THE  SPINE. 

Kyphosis. — As  has  been  stated  in  the  chapter  on  Pott's  dis- 
ease, the  spine  is  practically  straight  at  birth.  If  during  the 
early  weeks  of  life  an  infant  be  placed  in  the  sitting  posture  the 
head  falls  forward  and  the  spine  bends  into  a  long  posterior 
curve,  the  posture  of  weakness.  The  normal  anterior  convexity 
of  the  cervical  section  is  established  when  the  gain  in  muscular 
power  enables  the  infant  to  hold  the  head  erect,  and  that  of  the 
lumbar  region  when  the  pelvis  is  tilted  do^^mward  by  the  exten- 
sion of  the  thighs  in  the  erect  posture. 

In  the  erect  posture  the  constant  tendency  of  the  weight  of 
the  head  and  of  the  thoracic  and  abdominal  organs  is  to  draw 
the  spine  forward.  This  tendency  is  resisted  by  the  action  of 
the  posterior  muscles  of  the  trunk.  Whenever,  therefore,  the 
muscular  power  is  lessened  or  the  body  is  overburdened,  or 
whenever  the  spine  is  weakened  by  disease,  the  tendency  toward 
the  original  curve  of  weakness  becomes  apparent  (Fig.  166). 
Thus,  the  causes  of  an  abnormal  increase  in  the  jDOsterior  curva- 
ture of  the  spine  are  very  numerous.  It  is,  as  has  been  stated, 
the  characteristic  attitude  of  weakness,  as  is  illustrated  in  in- 
fancy and  in  old  age.  It  is  one  of  the  common  occupation 
deformities  of  adult  life;  it  is  a  common  postural  deformity  of 
childhood  and  adolescence.  It  may  be  induced  by  a  variety  of 
diseases  that  lessen  the  resistance  of  the  spine  or  that  interfere 


DEFOBMITIES  OF  THE  SPINE. 


225 


with  its  function.  For  example,  by  rhachitis,  spondylitis  de- 
formans, osteitis  deformans,  Pott's  disease,  and  affections  of  a 
similar  nature. 

The  kyphosis  of  rhachitis  is  most  marked  in  the  lower  region, 
that  of  spondylitis  deformans  may  involve  the  entire  spine, 
while  the  simple  postural  curvature  is  most  marked  in  the  upper 
dorsal  region — "  round  shoulders."  In  a  number  of  the  postural 
deformities  the  increase  in  the  dorsal  kyphosis  is  balanced  by  an 
increased  lordosis,  and  in  this  form  there  is  simply  an  exag- 

FiG.  167. 


Marked   posterior   curvature   of  the   spine   apparently   induced   by  weakness   Inci- 
dental to  illness. 


geration  of  the  normal  curves  of  the  spine — the  "  hollow  round  " 
back.  In  other  instances  there  is  a  general  forward  droop  of 
the  trunk  in  which  the  lumbar  lordosis  may  be  lessened ;  this 
form  is  more  common  in  childhood — the  "  round  "  back. 

The  forms  of  kyphosis  that  are  the  direct  result  of  disease 
have   been   described   elsewhere.      Postural   kyphosis — "  round 
15 


226 


OBTEOPEDIC  SUBGEB¥. 


shoulders  " — is  one  of  the  common  deformities,  and  in  child- 
hood its  etiology  is  similar  to  that  of  lateral  curvature,  of  which 
it  may  be  a  predisposing  cause.  Round  shoulders  and  thie 
accompanying  so-called  flat,  but  in  reality  narrow  and  therefore 
deeper,  chest  may  be  induced  also  by  obstructions  in  the  respira- 
tory passages,  such  as  enlarged  tonsils,  adenoids,  and  the  like, 
or  by  bronchitis  or  heart  disease.  Another  predisposing  cause 
is  clothing  that  prevents  the  full  expansion  of  the  chest  and  the 
extension  of  the  arms,  and  even  the  weight  of  clothing  suspended 

Fig.  168. 


Posterior  curvature  of  the  spine  in  adolescence  with  rigidity.     A  deformity  that 
may  be  mistalten  for  that   of  spondylitis   deformans. 


from  the  shoulders  may  be  a  factor  in  the  etiology.  These  and 
other  possible  contributing  causes  should  be  investigated  in  all 
cases  of  this  character. 

A  more  extreme  type  of  deformity  is  sometimes  seen  in  ado- 
lescents (Fig.  168),  induced  apparently  by  posture  and  by 
overwork,  although  in  most  instances  it  may  be  assumed  that  a 
slighter  deformity  of  long  standing  has  served  as  a  predisposing 
cause.     In  this  type  the  deformity  is  resistant,  and  is  accom- 


DEFOBMITIES  OF  THE  SPINE. 


227 


panied  by  adaptive  changes  in  the  vertebrae  that  prevent  com- 
plete correction. 

Ssmiptoms. — The  most  important  symptom  is  the  deformity 
itself.  In  adolescent  cases  there  is  often  some  discomfort  of 
the  nature  of  strain  and  tire  usually  referred  to  the  scapular 
region  but  in  the  rigid  type  the  pain  is  most  marked  below  the 
projection. 

Treatment. — Even  slight  posterior  curvatures  of  the  spine 
check  the  expansion  of  the  chest  and  disturb  the  balance  of  the 


Fig.  169. 


Fig.  170. 


Exercises  for  the  correction  of  posterior  curvatures  of  the  spine.      (Hoffa.) 


body.  ■  Furthermore  as  it  has  been  demonstrated  by  X-ray  pic- 
tures that  the  internal  viscera  may  be  lifted  from  three  to  six 
inches  by  muscular  effort  in  the  erect  posture,  it  is  apparent  that 
serious  and  permanent  displacement  of  these  organs  may  result 
from  habitual  deformity. 

The  treatment  is  similar  to  that  of  lateral  curvature.     The 
assumption  of  the  military  attitude,  with  the  head  erect,  the 


228 


OETHOPEDIC  SVBGEEY. 


cliin  depressed,  the  shoulders  thrown  back,  the  chest  expanded, 
and  the  abdomen  retracted,  should  be  encouraged.  And  those 
exercises  that  expand  the  chest  and  that  strengthen  the  muscles 
of  the  upper  jiart  of  the  spine  are  especiallv  important.  (Such 
exercises  are  illustrated  by  Figs.  112,  113,  119,  120,  131,  132, 
133,  134,  136,  139,  150,  and"  151.)  If  the  range  of  vertical 
extension  of  the  arms  is  limited,  this  restriction  must  be  over- 
come before  the  deformity  of  the  spine  can  be  permanently 
improved.  In  well-marked  cases  the  patient  should  be  encour- 
aged to  read  or  study  in  the  prone  posture.     In  this  attitude,  in 

Fig.  171. 


A  brace  for  round  shoulders.      (Goldthwait. 


which  the  trunk  must  be  supported  upon  the  elbows  and  the  head 
held  backward,  there  is  necessarily  an  involuntary  correction 
of  the  deformity.  In  certain  instances  a  light  spinal  brace  or 
corset  may  be  employed  during  the  hours  when  the  passive  atti- 
tude must  be  assumed  (Fig.  ITl).  Shoulder  braces,  so-called, 
are  useless,  because  the  lumbar  lordosis  is  increased  when  the 
shoulders  are  drawn  backward.  Clothing  should  not  restrict 
the  movements  of  the  arms  or  trunk,  and  as  little  weight  as 
possible  should  be  suspended  from  the  shoulders.  In  the  more 
extreme  cases  a  Calot  jacket  should  be  applied  as  described  in 
the  chapter  on  Pott's  disease.  If  the  kyphosis  is  of  long  dura- 
tion  and  rigid,   as  in  adolescent  cases,   forcible  manipulation 


DEFORMITIES  OF  THE  SPINE. 


229 


under  ansesthesia  may  be  of  service  before  applying  the  support. 
Afterward  treatment  by  manipulation,  exercise  and  posture  is 
continued  as  in  cases  of  the  ordinary  type.  Whenever  a  patient 
is  imder  treatment  for  deformity  of  the  trunk  the  attempt  should 
be  made  to  restore  the  proper  relation  of  the  body  and  limbs, 
and  thus  to  restore  the  general  symmetry  of  the  body.  Atten- 
tion is  again  called  to  weak  feet  as  the  most  common  and  im- 

FlG.  172. 


Lordosis  caused  by  spondylolisthesis. 

portant  accompaniment  and  predisposing  cause  of  deformities 
of  this  class. 

Lordosis. — Lordosis,  or  an  abnormal  hollowness  of  the  back, 
is  far  less  common  than  kyphosis.  It  is  not  a  simple  postural 
deformity,  but  it  is  usually  secondary  to  disease  or  deformity 
either  of  the  spine  or  of  the  adjoining  members.  For  example, 
lordosis  may  be  induced  by  flexion  contraction  of  the  thighs; 
it  is  a  symptom  of  congenital  displacement  of  the  hips ;  it  is 
sometimes  a  result  of  certain  forms  of  nervous  disease,  in  which, 
because  of  muscular  weakness,  the  body  is  swayed  backward  to 


230 


OETHOFEDIC  SUBGEBT. 


retain  tlie  balance,  as  in  the  muscular  dystrophies.  Lordosis 
in  the  lumbar  region  may  be  a  compensation  for  a  kyphosis  in 
the  upper  segment.  It  is  caused  directly  by  spondylolisthesis. 
It  may  be  a  congenital  deformity,  and  it  is  said  to  be  a  pecu- 
liarity of  contortionists  (Fig-  172). 

Treatment. — As  lordosis  is  usually  a  secondary  deformity  its 
treatment  would  be  included  in  the  treatment  of  its  causes.  In 
some  instances  the  discomfort  which  is  usually  present  when  the 
deformity  is  well-marked  may  be  relieved  by  a  proper  corset 
sufficiently  strong  to  support  the  back. 

CONGENITAL  ELEVATION  OF  THE  SCAPULA. 

Synonym. — Sprengel's  deformity. 

Sprengel's  deformity  is  a  congenital  elevation  of  the  scapula 
above  the  level  of  its  fellow,  an  elevation  accompanied  in  most 
instances  bv  rotation,  so  that  its  lower  angle  is  brought  nearer 


Fig.  173. 


Congenital  elevation  of  the  left  scapula  :  with  the  arm  elevated  the  scapula 
is  in  contact  with  the  occiput,  as  is  indicated  by  the  deep  fold ;  age  of  the 
patient  three  months. 

to  the  Spine  while  its  upper  border  projecting  and  bent  forward 
above  the  clavicle  has  in  several  instances  been  mistaken  for  an 
exostosis  (Fig.  173  j.  The  cervical  muscles  passing  to  the  scap- 
ula are  shortened  and  changed  in  direction  and  in  about  25  per 
cent,  of  the  cases  the  median  border  of  the  scapula  is  attached 
to  one  of  the  lower  cervical  vertebrse  by  a  bony  prolongation 
which  may  be  an  outgrowth  from  a  transverse  process  or  jointed 
at  either  extremitv.     Thus,  its  mobilitv  is  lessened  and  the 


DEFORMITIES  OF  THE  SPINE. 


231 


range  of  vertical  extension  of  the  arm  is  restricted.  The  de- 
formity may  be  combined  with  torticollis  or  with  cervical  ribs 
or  defective  formation  of  the  spine,  for  example,  absence  of 
vertebrEe  or  rhachischisis.  In  many  instances  there  is  an  accom- 
panying lateral  cnrvature  of  the  spine,  the  convexity  being 
nsuallv  toward  the  deformed  side.     ISTinety-nine  cases  have  been 


Congenital    elevation   of  the   scapular   of   a   moderate   degree   in   adolescence. 

collected  from  literature  recently  by  Zesas.^  Forty-seven  were 
of  the  right  side,  thirty-six  of  the  left,  and  in  eleven  both 
scapnlse  were  elevated.  Of  eighty-two  cases  forty-eight  were 
in  males.  The  most  recent  and  complete  review  of  the  subject 
is  by  A.'  E.  Horwitz^  of  136  cases.  Scoliosis  was  present  in  47 
per  cent.,  torticollis  in  10  per  cent.,  and  asymmetry  of  the  skull 
and  face  without  torticollis  in  11  per  cent.  In  67  per  cent,  there 
was  some  accompanying  defect  in  formation." 

'  Zeits.  f .  Ortli.  Chir.,  Band  xv.,  Heft  1,  1905. 

==Am.  J.  Orth.   Surg.,  Vol.   6,  1909,  No.   2. 

^The  deformity  was  first  described  by  Eulenburg  (Archiv  f.  klin.  Chir., 
1868),  but  in  more  detail  by  Sprengel  (Centralbl.  f.  Chir.,  1895),  who 
reported  four  cases  in  children  from  one  to  seven  years  of  age. 


232  OETHOPEDIC  SrSGEET. 

Etiology. — Tlie  etiology  is  doubtful,  but  iu  many  instances  it 
aj)pears  to  be  the  result  of  a  constrained  position  of  the  foetus. 
In  two  of  Sprengel's  cases,  seen  soon  after  birth,  the  arm  ap- 
peared to  have  been  fixed  behind  the  back  of  the  child. 

It  is  of  interest  to  note  that,  according  to  Chievitz,  the  upper 
limb  is  in  its  origin  a  cervical  appendage,  retaining  an  elevated 
position  during  foetal  life,  and  that  interference  with  its  descent 
by  constraint  or  otherwise  may  explain  the  etiology. 

Congenital  elevation  of  the  scapula  may  be  simulated  by  the 
distortion  and  muscular  atrophy  resulting  from  birth  palsy,  or 
even  by  certain  cases  of  rotary  lateral  curvature  in  which  the 
scapula  is  elevated  and  prominent. 

In  suitable  cases  all  the  shortened  tissues  should  be  divided 
through  an  open  incision  and  the  deformity  should  be  as  far  as 
possible  corrected  by  force.  A  fixation  support  of  plaster  of 
Paris  is  then  applied.  Supplemental  treatment  by  forcible 
stretching  is  afterwards  employed,  as  in  the  treatment  of 
torticollis. 

DEFICIENCY  AND   MALFORMATION   OF   VERTEBRA. 

Absence  of  vertebrae  is  usually  associated  with  rhachischisis. 
Several  cases,  however,  have  come  under  my  observation  in 
which  there  was  absence  of  vertebrae  without  other  malforma- 
tion. In  two  of  the  cases  the  deficiency  was  in  the  cervical 
region,  in  the  others  in  the  lumbar.  The  noticeable  shortness 
of  the  affected  section  of  the  spine  was  the  only  symptom. 
Supernumerary  and  otherwise  malformed  vertebra  have  recently 
been  demonstrated  by  X-ray  examinations  to  be  a  more  im- 
portant factor  in  the  etiology  of  deformity  of  the  spine  than  had 
been  susj)ected  formerly. 

ABNORMALITIES  OF  RIBS. 

Cervical  Ribs. — Cervical  ribs  are  not  uncommon.  The  rib 
may  be  complete,  articulating  with  the  body  or  transverse  process 
of  the  seventh  cervical  vertebra  and  with  the  sternum,  or  incom- 
plete, connected  by  ligament  with  the  sternum  or  first  rib,  or  it 
may  be  simply  an  elongated  transverse  process.  In  most  in- 
stances the  anomaly  is  bilateral  but  more  developed  on  one  than 
on  the  other  side. 

If  the  rib  is  unilateral  it  is  often  connected  with  a  defective 
supernumerary  vertebra.  In  such  instances  the  spine  is  often 
deflected  to  form  a  lateral  curvature  toward  the  abnormal itv. 


DEFOBMITIES  OF  TEE  SPINE. 


233 


If  the  ribs  are  complete  the  neck  appears  wide  and  short  and 
the  projecting  ribs  may  be  felt  as  bony  prominences  (Fig.  175). 


The  subject  is  of  surgical  interest  because  a  number  of  cases 
have  been  reported  in  which  pressure  on  the  nerves  and  blood- 


234  OBTEOPEDIC  SUBGEEY. 

vessels  induced  pain  and  even  paresis  of  the  arm  and  feeble 
circulation.  Such  symptoms,  as  a  rule,  do  not  appear  until  ado- 
lescence or  adult  life.  The  treatment  is  resection  of  that  portion 
of  the  rib  that  causes  pressure.^  In  these  cases  the  artery  is 
usually  above  and  the  vein  below  the  rib. 

Absence  of  Ribs. — Absence  or  defective  formation  of  ribs  is 
uncommon.  In  such  cases  there  is  usually  defective  formation 
of  the  corresponding  muscles,  and  lateral  curvature  of  the  spine 
is  often  present. 

MALFORMATION  OF  PECTORAL  MUSCLE. 

Several  instances  in  which  one  or  both  of  the  pectoral  muscles 
were  defective  or  absent  have  been  observed  at  the  Hospital  for 
Euptured  and  Crippled.  The  malformation  in  these  cases 
caused  no  direct  symptoms.^ 

ABNORMALITY  6F  CLAVICLE. 

Thirty-eight  cases  of  defective  formation  of  the  clavicle  on 
one  or  both  sides  are  recorded.^  Of  27  cases  reported  by 
Heinecke^  the  defect  was  bilateral  in  20.  In  most  instances  a 
portion  of  the  sternal  extremity  is  present.  The  defect  appears 
to  cause  but  slight  inconvenience. 

DEFORMITIES  OF  THE  CHEST. 

Flat  Chest. — The  so-called  flat  chest  is  an  accompaniment  of 
the  round  back  (Fig.  166).  The  shoulders  and  scapulae  being 
displaced  forward  the  chest  becomes  less  prominent. 

Woods  Hutchinson  has  called  attention  to  the  fact  that  the 
so-called  flat  chest  is  in  reality  a  round  chest,  in  the  sense  that 
the  thorax  is  actually  deeper  than  the  normal,  a  persistence  of 
the  fcetal  type.  He  suggests  that  such  persistence  may  be  one 
of  the  causes  of  round  shoulders,  the  round  chest  affording  no 
adequate  support  for  the  scapulae. 

Hutchinson^  has  presented  an  index  showing  the  relative 
depth  of  the  chest  at  different  ages,  illustrating  the  progress 
from  the  keel  chest  of  the  lower  orders  to  the  bellows-shape  of  the 
adult  human  form.  This  index  is  found  by  dividing  the  antero- 
posterior diameter  at  the  nipples  by  the  transverse  diameter  at 

^  Eoberts,  Journal  American  Medical  Association,  Oct.  3,  1908. 
^Martirene,  Kevue  cl 'Orthopeclie,  May,  1903. 
^Klar,   Zeits.   f.   Orth.   Chir.,   Bd.   xv..  Heft   2,   1906. 
*Zeits.  f.  Orth.  CMr.,  Band  xxi..  Heft  4,  1908. 

^Journal  American  Medical  Association,  September  11,  1897,  and  May 
2,  1903. 


DEFORMITIES  OF  THE  SPINE. 


235 


the  same  level ;  hence  the  lower  index,  the  longer  and  flatter, 
more  bellows-like  the  chest. 

Embryo    105-115 

At  birth 101 

Under  2  years 94 

■  3-7  years 85 

14-18  years 80 

Adult    72 

Treatment. — The  treatment  of  the  so-called  flat  chest  is  simi- 
lar to  that  of  the  round  shoulders,  with  which  it  is  combined — 
that  is,  by  exercises  conducted  with  the  special  object  of  improv- 
ing the  strength  of  the  muscles  of  the  back  and  increasing  the 
expansion  of  the  upper  part  of  the  chest.  The  importance  of 
correcting  the  deformity,  which  interferes  with  the  proper  ex- 
pansion of  the  lungs  and  thus  predisposes  to  disease,  should  be 
evident. 

Pigeon  Chest Synonym. — Pectus  carinatum. 

Fig.  176. 


General  rhachitic  distortious  and  pigeon  chest. 


236  OETHOPEDIC  SUEGEEY. 

The  i3igeoii,  or  keel-shaped,  chest  resembles  the  quadrupedal 
type  in  that  the  anteroposterior  is  increased  at  the  expense  of 
the  lateral  diameter.  The  sternum  is  thrust  forward  and  down- 
ward like  the  keel  of  a  boat,  the  lateral  compression  being  most 
marked  at  the  junction  of  the  ribs  and  the  cartilages.  This 
deformity  is  almost  always  acquired  (Fig.  176)  ;  it  is  usually 
an  effect  of  rhachitis,  and  it  is  described  under  that  heading. 
It  may  be  induced  by  obstruction  of  respiration  caused  by  en- 
larged tonsils  and  the  like,  if  this  is  present  at  an  early  age.  It 
may  be  a  secondary  effect  of  the  sinking  forward  and  downward 
of  the  uj)per  half  of  the  trunk,  as  in  Pott's  disease. 

Treatment. — The  treatment  of  secondary  deformity  would  be 
included  in  the  treatment  of  the  affection  of  which  it  is  the 
result.  Manipulation,  massage,  and  breathing  exercises  may  be 
employed  in  the  treatment  of  simple  pigeon  chest.  The  tend- 
ency is  toward  spontaneous  cure ;  it  is  rarely  seen  in  adult  life. 

Funnel  Chest Synonym. — Pectus    excavatum. 

This  deformity  (Fig.  177)  is  the  reverse  of  the  pigeon  chest. 
The  sternum  is  depressed  and  the  lateral  diameter  of  the  thorax 
is  correspondingly  increased.  The  milder  types  of  the  affection 
in  which  there  are  one  or  more  depressions  or  hollows  in  the 
sternum  are  common.  The  extreme  form,  in  which  the  entire 
sternum  is  depressed,  is  rare.  It  is  practically  always  a 
congenital  deformity,  and  it  is  not  susceptible  to  direct  treat- 
ment. 

Minor  Deformities  of  the  Chest. — As  has  been  stated,  distor- 
tions of  the  chest  secondary  to  deformity  of  the  spine  are  often 
discovered  before  the  original  cause  is  suspected.  And  the  im- 
portance of  the  various  minor  irregularities  of  the  chest  or  in 
the  direction  of  the  ribs  when  once  discovered  is  often  exag- 
gerated. They  are  usually  the  result  of  preceding  rhachitis. 
The  increase  of  the  capacity  of  the  chest  by  appropriate  exercises 
aids  in  the  correction  of  asymmetry. 

SCAPULAR  CREPITUS. 

Creaking  or  grating  sounds  induced  by  certain  movements  of 
the  scapula  on  the  thorax  sometimes  appear  without  apparent 
cause  or  are  developed  by  exercises  during  the  treatment  of 
lateral  curvature.    In  some  instances  bony  irregularities,  bursas, 


DEFORMITIES  OF  THE  SPINE.  237 

and  the  like  may  be  present.     Twenty-two  cases  are  reported  by 

Kuttner,^ 

Fig.  177. 


Pectus  excuvatum.     This  patient  has  ocular  torticollis  also. 

.  ACQUIRED  LUXATION  OR  SUBLUXATION  OF  THE 
CLAVICLE. 

Partial  displacement  of  the  sternal  end  of  the  clavicle  is  not 
particularly  uncommon.  In  some  instances  it  is  caused  by 
injury;  in  others  no  cause  can  be  assigned.  Most  often  there 
appears  to  be  a  laxity  of  the  capsular  ligament  that  permits  a 
displacement  during  certain  movements  of  the  arm.  The  dis- 
placement is  readily  reduced,  but  the  weakness  and  insecurity 
may  cause  discomfort  and  disability. 

Treatment. — In  some  instances  the  displacement  may  be  pre- 
vented by  the  pressure  of  a  pad  and  truss  spring,  attached  behind 
to  the  corset  or  braces  and  passing  over  the  shoulder  close  to  the 

^  Deutsch.  mecl.  Wochenschrift,  June  23,  1904. 


238 


OETHOPEDIC  SUBGEBT. 


neck.  Such  an  appliance  is  especially  useful  if  the  displacement 
occurs  at  certain  times  only,  as  in  dressing  the  hair,  playing  on 
the  violin,  etc.  Cures  are  reported  as  the  result  of  the  injection 
of  alcohol  into  the  joint  from  time  to  time,  and  Wolffs  has  oper- 
ated with  success  as  follows:  The  joint  is  opened  by  a  straight 
incision.  A  fragment  of  bone  is  detached  from  the  clavicle 
above  and  a  similar  one  from  the  sternum;  these,  still  adherent 

Fig.  178. 


Hypertropliy  of  the  right  forearm  and  hand,  due  to  congenital  nfevus. 

to  the  periosteum,  are  overlapped  in  front  of  the  joint  and  the 
capsule  is  then  sutured.  As  a  rule  the  affection  is  not  of  par- 
ticular importance. 


ASYMMETRICAL  DEVELOPMENT. 

In  normal  individuals  there  is  often  a  slight  difference  be- 
tween the  two  halves  of  the  body,  and,  as  is  well  known,  in- 
equality  in  the  length  of  the  legs   is  not   at  all-  uncommon. 
^Centralbl.   f.   Chir.,  November   30,   1893. 


BEFOEMITIES  OF  THE  SPINE. 


239 


Inequality  of  the  two  halves  of  the  body  may  be  congenital,  and 
it  may  be  evident  at  birth,  but  usually  it  does  not  attract  atten- 
tion until  adolescence.  In  many  instances  this  inequality  is  a 
slight  atrophy,  the  result  of  a  cerebral  hemiplegia  of  early 
childhood.  In  other  instances  the  inequality  may  be  due  to  con- 
genital hypertrophy  that  may  affect  the  entire  limb.  In  such 
cases  the  enlargement  may  be  due  to  an  abnormal  amount  of 
normal  tissue,  but  in  most  instances  the  hypertrophy,  which 
becomes  more  marked  with  the  growth  of  the  child,  is  caused  by 
an  abnormal  blood  supply,  a  form  of  congenital  nsevus 
(Fig.  178). 

Table  of  Weight,  Height,  and  Circumference  of  the  Chest  in  Child- 
hood.    (Boas.) 


Birth 

6  months. 

1  year 

18  months 

2  years  ... 
3 


4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 


f  Male 
(  Female 
(  Male 
{  Female 
(  Male 
\  Female 
f  Male 
\^  Female 
(  Male 
\  Female 
f  Male 
\  Female 
f  Male 
\  Female 
r  Male 
\  Female 
f  Male 
t  Female 
r  Male 
\  Female 
t  Male 
\  Female 
I  Male 
\  Female 
f  Male 
(  Female 
f  Male 
\  Female 
(  Male 
(  Female 
r  Male 
1  Female 
f  Male 
{  Female 
(  Male 
\  Female 


Pounds. 


7.55 
7.16 
16.0 
15.5 
20.5 
19.8 
22.8 
22.0 
26  5 
25.5 
31.2 
.30.0 
35.0 
34.0 
41.2 
39.8 
45.1 
43.8 
49.5 
48.0 
54.5 
52.9 
60.0 
57.5 
66.6 
64.1 
72.4 
70.3 
79.8 
81.4 
88.3 
91.2 
99.3 
100.3 
110.08 
108.04 


Kilos. 


3.43 
3.26 
7.26 
7.03 
9.29 
8.84 
10.35 
9.98 
12.02 
11.56 
14.14 
13.60 
15.87 
15.41 
18.71 
18.06 
20.48 
19.87 
22.44 
21.78 
24.70 
24.01 
26.58 
26.10 
30.22 
29.07 
32.83 
31.87 
36.21 
36.90 
40.04 
41.36 
45.03 
45.50 
50.26 
49.17 


Height. 


Inches. 


20.6 
20.5 
25.4 
25.0 
29.0 
28.7 
30.0 
29.7 
32.5 
32.5 
35.0 
35.0 
38.0 
38.0 
41.7 
41.4 
44.1 
43.6 
46.2 
45.9 
48.2 
48.0 
50.1 
49.6 
52.2 
51.8 
54.0 
53.8 
55.8 
57.1 
58.2 
58.7 
61.0 
60.3 
63.0 
61.4 


Cm. 


52.5 

52  2 

64.8 

64.6 

73.8 

73.2 

76.3 

75.6 

82.8 

82.8 

89.1 

89.1 

96.7 

96.7 

106.8 

105.3 

112.0 

110.9 

117.4 

116.7 

122.3 

122.1 

127.2 

126.0 

132.6 

131.5 

137.2 

136.6 

141.7 

145.2 

147.7 

149.2 

155.1 

153  2 

159.0 

155.9 


Chest. 


Inches. 


13.4 
13.0 
16.5 
16.1 
18.0 
17.4 
18.5 
18.0 
19.0 
18.5 
20.1 
19.8 
20.7 
20.5 
21.5 
21.0 
23.2 
22.8 
23.7 
23.3 
24.4 
23.8 
25.1 
24.5 
25.8 
24.7 
26.4 
25.8 
27.0 
26.8 
27.7 
28.0 
28.8 
29.2 
30.0 
30.3 


Cm. 


34.2 

33.2 

42.0 

41.0 

45.9 

44.4 

47.1 

45.9 

48.4 

47.0 

51.1' 

50.5 

52.8 

52.2 

54.8 

53.5 

59.1 

58.3 

60.6 

59.5 

62.2 

60.8 

63.9 

62.5 

65.6 

63.0 

67.2 

65.8 

68.8 

68.3 

70.6 

71.3 

73.3 

74.1 

76.6 

79.8 


240 


ORTHOPEDIC  SUEGEBY. 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY. 

Wolff's  Law. — "Every  change  in  the  form  and  function  of 
the  bones  or  of  their  function  alone  is  followed  by  certain 
definite  changes  in  their  internal  architecture,  and  equally 
definite  secondary  alternations  of  their  external  conformation, 
in  accordance  with  mathematical  laws." 

Mention  has  been  made,  and  will  be  made  again  from  time  to 
time,  of  the  adaptation  of  the  body  to  abnormal  conditions,  and 

Fig.  179. 


Dislocated  femur,  showing  the  atrophy  and  rearrangement  of  the  internal  struc- 
ture as  compared  with  the  normal    (Pig.  ISO).      (Freiberg.) 

of  the  transformation  of  deformed  parts  to  the  normal  when  the 
improper  relations  of  weight  and  strain  have  been  removed. 
Wolff  first  called  attention  to  the  fact  that  the  shape  of  a  bone 
is  the  effect  of  function.  It  is  the  effect  of  function  in  that  if 
the  work  required  of  it  had  been  different  its  shape  would  have 
been  dift'creut.  This  function  has  shaped  not  only  the  external 
contour  but  the  internal  structure  as  well.     If  a  bone  is  broken, 


DEFOBMITIES  OF  THE  SPINE. 


241 


for  example,  the  neck  of  the  femur,  and  deformity  results,  the 
internal  architecture  is  no  longer  suitable  for  the  new  conditions 
of  weight  and  strain,  and  immediately  a  rearrangement  begins, 
which  finally  transforms  the  internal  structure,  not  only  in  the 
neighborhood  of  the  injury,  but  in  the  extremity  of  the  bone 
also,  to  adapt  the  deformed  part  as  well  as  may  be  to  the  work 
that  is  now  demanded  of  it. 

The  normal  bone  is  braced  most  thoroughly,  and  is  most  re- 
sistant at  the  points  where  most  work  is  required  of  it.     If  the 

Fig.  180. 


Normal  femur  from  same  subject.      (Freiberg.) 


weight  and  strain  are  for  any  reason  transferred  to  another  part, 
its  structure  is  strengthened  there,  and  correspondingly  weak- 
ened at  the  point  from  which  the  strain  has  been  removed. 
With  this  change  in  the  internal  structure  a  change  in  the  ex- 
ternal contour  keeps  pace.  For,  according  to  this  theory,  "  the 
external  contour  represents  mathematically  simply  the  last  curve 
uniting  the  ends  of  the  various  trajectories  which  make  up  the 
internal  structure." 
16 


242 


OBTEOPEDIC  SUEGEB¥. 


For  the  further  exposition  of  this  theory  I  quote  from  Frei- 
berg's-^ review  and  abstract  of  Wolff's^  final  article. 

"In  showing  that  improper  static  demands  made  upon  an 
extremity  resulted  in  the  formation  of  new  masses  of  bone  upon 
the  surface  of  the  bone  of  this  extremity,  or  that  they  produce 
the  disappearance  (atrophy)  of  bone  masses  according  to  the 
nature  and  degree  of  these  disturbances  in  static  requirements, 

Fig.  181. 


Section  of  femoral  head  of  a  paralytic  idiot,  aged  thirty-five  years,  showing  the 
extreme   atrophy   caused  by   disuse.      (R.   T.   Taylor.) 


it  has  at  once  been  shown  in  what  manner  deformities  have  their 
origin.  For  these  transformations  on  the  surface  of  bone  are 
nothing  other  than  '  deformities '  in  the  wider  or  narrower  sense 
of  the  term. 

"  Taking  genu  valgum  or  habitual  scoliosis  as  an  example,  the 
development  of  a  deformity  in  the  narrow  sense  is  thus  ex- 
plained. In  the  beginning  of  either  of  these  conditions  the  shape 
of  the  bones  is  perfectly  normal.  As  the  result  of  excessive 
fatigue  in  their  too  weak  muscles  the  patients  are  frequently 
assuming  a  faulty  position  of  limb  or  body ;  they  seek  to  control 
excessive  excursions  of  their  joints  by  the  interference  of  the 
articular  structures  themselves  instead  of  by  muscular  activity. 
The  result  is  a  continual  alteration  in  the  static  requirements 
made  upon  the  bones  and  the  internal  architecture ;  internal  and 

^Annals  of  Surgery,  July,  1897;  and  American  Journal  of  the  Medical 
Sciences,  December,  1902. 

'■'  Die  Lehre  von  der  functionellen  Pathogenese  der  Deformitaten,  Archiv 
f.  klinisehe  Chirurgie,  Bd.  liii.,  H.  4. 


DEFORMITIES  OF  THE  SPINE.  243 

external  configuration  of  the  bones  accommodate  themselves  to 
the  new  conditions.  Since,  according  to  this  reasoning,  deformi- 
ties are  nothing  less  than  the  result  of  these  transformations 
which  the  external  form  of  bones  or  joints  undergo  in  accommo- 
dating itself  to  faulty  demands  made  upon  them,  it  must  be 
self-evident  that  these  deformities  are  to  be  considered  patho- 
logical only  in  the  sense  that  hypertrophy  of  the  cardiac  muscle 
in  valvular  insufficiency  is  pathological.  That  which  is  really 
pathological  is  only  the  altered  static  requirements,  the  abnormal 
mechanical  function.  Far  from  being  pathological  the  de- 
formity is  the  only  suitable  or  even  possible  form  by  means  of 
which  bone  or  joint  can  withstand  the  altered  forces  bearing 
upon  it;  it  is  nature's  way  of  securing  the  greatest  possible 
service  and  strength,  under  new  conditions,  with  the  use  of  the 
least  possible  amount  of  material. 

"  The  pathogenesis  of  deformities  is,  therefore,  functional. 
Genu  valgum,  for  instance,  represents  only  the  functional  ac- 
commodation of  femur,  tibia,  and  knee-joint  to  the  improper 
static  demands  made  by  the  outward  deviation  of  the  leg.  Just 
so  are  the  shapes  of  the  bones  in  club-foot  the  expressions  of 
similar  functional  accommodation  to  an  inward  rotation  of  the 
foot,  or  even,  sometimes,  an  inward  turning  of  the  whole  lower 
extremity.  The  faulty  position  of  an  extremity  under  these 
circumstances  is  to  be  regarded  rather  as  a  cause  of  the  de- 
formity than  as  an  effect.  This  faulty  position  must  always 
occupy  a  place  intermediate  between  the  remote  causes  of  de- 
formity (hereditary  predisposition,  habit,  muscular  weakness, 
external  conditions  causing  pressure  or  narrowing  space  of 
growth),  and  the  anatomical  results  which  these  various  remote 
causes  bring  about. 

"When  the  altered  demands  upon  an  extremity  do  not  occur 
spontaneously,  as  in  the  above  instances,  but,  on  the  other  hand, 
result  from  a. primary  disturbance  in  the  shape  of  the  bones, 
due  to  trauma  or  bone  disease  with  consequent  softening  or 
destruction  of  tissue,  there  is  added  to  this  a  secondary  change 
in  the  external  configuration  of  the  bones,  and  there  is  thus 
caused  a  '  deformity  in  the  broad  sense  of  the  word.'  The  differ- 
ence between  the  two  varieties  of  deformity,  therefore,  lies  only 
in  the  addition  of  a  second  etiological  factor  (the  trauma,  etc.) 
to  the  deformity  in  the  broad  sense.  Both  varieties  have  it  in 
common  that  the  shape  of  the  bones  and  joints  of  the  deformed 
part  represents  nothing  else  than  the  ei^pression  of  a  functional 
accommodation  to  the  faulty  static  demands  made  upon  it. 


244  OETHOPEDIC  SUBGEEY. 

"  As  a  second  example  by  means  of  which  to  explain  the  cor- 
rectness of  the  doctrine  of  functional  pathogenesis  the  author  has 
selected  scoliosis.  In  the  first  chapter  the  author  showed  in 
detail  that  the  altered  conditions  in  the  length  and  height  of  the 
transverse  processes  of  scoliotic  vertebrae  as  well  as  correspond- 
ing conditions  in  the  ribs  of  the  scoliotic  thorax  are  so  evident 
as  not  possibly  to  escape  notice,  and  that  they  can  be  explained 
in  no  other  way  than  as  functional  accommodation  to  the  cir- 
cumstances of  space,  changed  and  brought  about  by  the  con- 
tinual, faulty,  and  cramped  position  of  the  thorax ;  this  is  as 
true  of  the  convex  as  of  the  concave  side  of  the  vertebral  column, 
to  which  the  transverse  processes  and  ribs  in  question  belong. 
It  must  be  manifest  that  changed  relations  of  one  part  of  the 
skeleton  to  any  other  part  of  the  skeleton  (as  far  as  space  condi- 
tions are  concerned)  necessarily  bring  about  changes  in  the 
mechanical  demands  made  upon  this  part,  and,  therefore, 
changes  in  the  directions  and  values  of  the  pressure,  tension, 
and  shearing  strains  of  each  and  every  point  in  this  part  of  the 
skeleton.  The  conclusion  thus  drawn,  that  accommodation  to 
space  means  the  same  as  accommodation  to  function,  is  of 
greatest  importance  to  the  general  doctrine  of  functional  ac- 
commodation. 

"  The  origin  of  the  wedge-shape  of  the  scoliotic  vertebra  now 
comes  under  discussion.  It  is  assumed  by  the  majority  of 
writers  that  an  abnormal  softness  of  the  bones  is  present  in 
scoliosis  by  means  of  which  a  faulty  position  can  model  the 
bodies  of  the  vertebra  as  it  does  in  the  case  of  rhachitic  disease 
of  the  bone,  or  as  is  really  the  case  with  the  intervertebral  disks 
in  cases  of  '  habitual  scoliosis.'  While  unsupported  by  any 
pathologico-anatomical  investigations,  it  is  allowed  possible,  or 
even  probable,  that  such  softness  of  the  bones  plays  a  role  in  many 
cases  of  scoliosis.  It  is  certain,  however,  that  this  is  by  no 
means  always  the  case;  as  evidenced  by  the  development  of 
scoliosis  after  empyema  in  adults,  and  the  great  exaggeration  in 
adult  life  of  very  slight  scolioses  originating  during  youth.  It 
is  concluded,  on  the  contrary,  that  the  vertebra  may  acquire  its 
scoliotic  Avedge-shape  entirely  independent  of  the  pressure  of  the 
superincumbent  weight.  Furthermore,  in  the  absence  of  any 
abnormal  softness  of  the  bones,  the  body  of  a  vertebra  may  lose 
height  on  the  concave  side  and  gain  the  same  on  the  convex  side 
through  the  '  tropic  stimulus  of  function '  purely ;  being  simply 
an  accommodation  to  the  diminished  space  on  the  concave  side 


DEFOBMITIES  OF  THE  SPINE.  245 

and  increased  room  at  the  convexity  and  the  change  of  mechan- 
ical conditions  consequent  thereupon. 

"  This  simple  and  natural  conception  of  the  circumstances 
concerning  the  scoliotic  wedge  must  obtain  credence,  especially 
since  the  old  view,  corresponding  to  the  '  pressure  theory,'  has 
been  long  ago  disproved  by  Hoffa  and  JSTicoladoni — namely,  that 
the  concave  side  of  the  wedge  is  the  seat  of  atrojDhy,  and  that 
this  atrophy  accounts  for  the  loss  in  height  of  the  vertebral  body 
on  this  side." 

The  importance  of  Wolff's  theory,  which  shows  how  deformity 
may  be  acquired  and  how  it  may  be  avoided,  is  very  evident. 
It  is  of  equal  importance  in  indicating  the  principles  of  treat- 
ment. For  example,  from  the  anatomical  description  of  a  club 
foot  the  distortion  might  appear  to  be  irremediable,  but  on  this 
theory  one  feels  assured  that  if  the  foot  can  be  fixed  for  a  suffi- 
cient time  in  the  overcorrected  position,  the  influence  of  the  new 
static  conditions  will  induce  a  gradual  transformation,  not  only 
in  soft  parts,  but  in  the  bones  as  well,  that  will  finally  effect  a 
complete  cure.  So,  also,  the  correction  of  a  distorted  bone  by 
operative  means  is  at  best  imperfect ;  if,  however,  the  static  con- 
ditions have  been  changed,  nature  will  in  time  reconstruct  the 
entire  bone  so  perfectly  that  in  a  few  years  practically  no  trace 
of  the  former  distortion,  either  in  contour  or  internal  structure, 
will  be  evident.  Scoliosis  might  be  cured  as  perfectly  as  the 
club  foot  or  the  bow-leg,  were  it  possible  to  restore  as  easily  the 
normal  conditions  of  weight  and  strain. 

ATROPHY  OF  BONE. 

The  writings  of  Wolff  have  emphasized  the  fact  that  bone  is 
a  living  tissue  very  readily  affected  by  changing  conditions,  and 
that  atrophy  or  hypertrophy  may  be  local  or  general,  according 
to  the  change  in  functional  use  of  the  affected  part. 

Since  the  Roentgen  ray  has  come  into  general  use  particular 
attention  has  been  called  to  the  atrophy  of  the  internal  structure 
of  bone  that  follows  lessened  use  or  disuse,  or  from  what  is 
called  trophic  disturbance  of  nutrition  from  any  cause.  For 
example,  after  fracture  or  joint  disease,  or  nervous  affections, 
or  even  slight  injuries  of  the  nature  of  sprains,  atrophy  of  the 
lamellae  of  the  spongy  portion  and  of  the  compact  substance  of 
the  bone  is  soon  apparent. 

This  atrophy  is  not  only  rapid,  but  it  may  be  widespread,  as 


246  OBTHOPEDIC  SUEGEBY. 

proved  bj  the  investigations  of  Sudeck/  who  could  distinguish 
atrophy  of  the  bones  of  the  foot  within  six  weeks  after  fracture 
of  those  of  the  leg.  Atrophy  of  bone  is  especially  rapid  as  a 
result  of  acute  affections  of  the  joints,  corresponding  in  this  to 
the  atrophy  of  the  muscles  under  similar  conditions.  In  the 
X-ray  negative  such  atrophy  is  indicated  by  a  loss  of  clearness 
of  outline  which  is  replaced  by  a  peculiar  blur,  resembling 
closely  the  infiltration  due  to  disease. 

These  nutritive  changes  explain  the  delay  in  recovery  after 
apparently  slight  injury  or  disease  of  a  joint  or  other  tissue. 
The  treatment,  therefore,  should  be  stimulative,  and  functional 
use  of  the  weak  part  should  be  encouraged  as  soon  as  possible.^ 

After  long-continued  disuse  the  bones  may  be  extremely 
fragile.  This  must  be  borne  in  mind  when  one  attempts  to 
correct  deformity  caused  by  paralysis,  by  chronic  joint  disease, 
and  the  like. 

HYPERTROPHY  OF  BONE. 

This  is  usually  due  to  disease.  It  may  be  general,  as  in 
osteitis  deformans.  It  may  affect  corresponding  bones,  as  in 
syphilitic  enlargement  of  the  tibise,  or  it  may  be  limited  to  a 
single  bone.  Of  this  a  familiar  example  is  chronic  osteomyelitis, 
which  may  induce  thickening  and  elongation  of  the  affected 
bone  sometimes  to  the  extent  of  two  or  more  inches. 

^  Fortsc.  auf  dem  Gebiets.  der  Eontgenstrahlen,  Bd.  iii.,  H.  6. 
-  Mally  et  Eichon,  Eevue  de  Chir.,  vols.  xxiv.  and  xx\'. 


CHAPTER  y. 
TUBERCULOUS  DISEASE   OF   THE  BONES   AND  JOINTS. 

Etiology. — Three  factors  are  recognized  in  the  etiology  of 
tuberculous  disease :  the  infectious  element  (the  tubercle  bacil- 
lus), the  predisposition  of  the  patient,  and  the  local  condition 
that  favors  the  reception  and  the  growth  of  the  bacilli. 

Predisposition. — The  predisposition,  both  general  and  local,  is 
spoken  of  as  lessened  vital  resistance.  A  general  predisposition 
to  disease  may  be  inherited  or  it  may  be  acquired.  Thus,  a 
history  of  tuberculosis  in  the  immediate  family  of  the  patient 
is  supposed  to  imply  a  lessened  resistance  to  this  form  of  disease. 
In  a  certain  proportion,  perhaps  25  per  cent.,  of  the  cases  this 
inherited  predisposition  is  very  direct  and  positive,  but  in  the 
larger  number  the  family  history  is  as  indefinite  as  in  a  similar 
class  of  patients  under  treatment  for  any  other  disease.  The 
acquired  predisposition  is  of  more  direct  importance,  since  it 
would  include  the  lessened  vitality  due  to  improper  food  and 
improper  hygienic  surroundings  of  every  variety,  together  with 
the  greater  liability  to  depressing  diseases  and  the  more  con- 
stant exposure  to  tuberculous  infection  that  such  conditions 
imply.  Thus,  tuberculous  disease  of  the  bones,  as  well  as  of 
other  parts,  is  more  common  among  the  poor  of  cities  than 
among  the  rnore  favored  classes. 

Mode  of  Infection. — The  tubercle  bacilli  may  be  introduced  to 
the  body  by  inhalation  and  find  their  way  to  the  bronchial 
glands,  or  by  the  mouth  and  set  up  disease  in  the  mesenteric 
glands,  or,  infection  through  the  nasal  passages  or  neighboring 
parts,  may  cause  disease  of  the  cervical  lymphatics. 

Latent  Tuberculosis. — It  may  be  assumed  that  disease  of  the 
bronchial  and  mesenteric  glands  is  not  uncommon  in  individuals 
of  apparently  perfect  health,  since  it  is  often  discovered  at 
autopsies  in  those  who  have  died  from  other  causes.  For  ex- 
ample in  2713  autopsies  on  children  who  died  of  acute  infectious 
diseases  reported  by  Ganghofner  tuberculous  disease  was  found 
in  562  or  about  20  per  cent.  This  form  of  glandular  disease  is 
called  latent  tuberculosis.  In  many  instances  the  disease  may 
remain  latent  and  finally  disappear,  or  it  may  persist,  and  from 

247 


248  OBTHOPEDIC  SUEGEEY. 

time  to  time  free  bacilli  or  bits  of  infected  tissue  may  escape 
into  the  blood  and  are  deposited  in  other  parts,  where,  under 
favoring  conditions,  local  disease  may  be  set  up.  Depression 
of  the  vitality  from  any  cause  should  favor  the  progress  of  the 
glandular  disease,  and  dissemination  of  the  infectious  elements. 
It  should  also  lessen  the  resistance  of  the  tissues  exposed  to 
infection.  This  accounts  for  the  well-known  influence  of  certain 
diseases,  such  as  measles  and  whooping-cough,  not  only  in  pre- 
disposing to  local  tuberculous  disease,  but  in  favoring  its  prog- 
ress when  it  is  already  established.  It  is  possible,  also  that  the 
bacilli  that  have  found  their'  way  into  the  blood  current  more 
directly,  as,  for  example,  through  wound  infection,  may  set  up 
primary  disease  of  a  bone  or  joint.  In  fact,  it  is  stated  by 
Koenig^  that  in  fourteen  of  sixty-seven  autopsies  on  subjects  who 
had  suffered  from  tuberculous  disease  of  the  bones  and  joints, 
no  other  foci  were  found  in  the  body.  In  other  instances  the 
source  of  infection  may  be  pre-existent  disease  of  the  lungs  or 
of  other  internal  organs. 

In  769  autopsies  on  children  under  twelve  years  of  age,  at  the 
Hospital  for  Children,  Great  Ormond  Street,  London,  reported 
by  Gr.  r.  Still, ^  269  presented  tuberculous  lesions.  Of  these, 
117  were  less  than  two  years  of  age. 

The  apparent  channels  of  infection,  as  evidenced  by  the  ap- 
pearance of  the  glandular  lesions,  were  as  follows : 

Eespiratory : 

Lungs 105 

Probably  lungs 33 

Ear  9 

Probably  ear 6 

153  =  57  per  cent. 

Alimentary: 

Intestines 53 

Probably  intestines  10^ 

63  =  23.4  per  cent. 

Other  cases: 

Bones  or  joints 5 

Fauces  2 

Uncertain    46 

53 

ISTorthrup  and  Bovaird^  have  made  similar  observations  at  the 
ISTew  York  Foundling  Hospital: 

^  Deutsche  Chir.,  1900,  L.  28a,  S.  157. 
-  British  Medical  Journal,  August  19,  1899. 

'  Northrup,  New  York  Med.  Journal,  February  21,  1891.  Bovaird,  Ibid., 
July  1,  1899. 


TUBEBCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.    249 

Infection  by  respiratory  tract 148 

Infection  by  mesenteric  lymph  nodes 3 

Indeterminate   48 

199 

In  sixteen  instances  the  process  was  confined  to  the  bronchial 
glands,  and  in  no  instance  were  these  giands  found  to  be  free 
from  disease. 

Bovaird^  has  collected  the  reported  autopsies  on  tuberculous 
children  with  reference  to  primary  intestinal  infection,  and  has 
called  attention  to  the  fact  that  the  English  observations  are  not 
in  accord  with  others  : 

Autopsies.  Primary  intestinal  disease. 

German   236  9  ^=    4  per  cent. 

French    128  0 

English 748  136  ==  18  per  cent. 

American   369  5^1  per  cent. 

1481  150 

Haushalter,"  in  78  autopsies  upon  children  dying  from  acute 
miliary  tuberculosis,  found  in  all  but  4  disease  of  the  tracheo- 
bronchial glands.  In  44  this  disease  was  the  most  ancient  focus 
in  the  body. 

Local  Predisposition. — The  local  conditions  that  favor  the 
growth  of  the  tubercle  bacilli  may  be  induced  by  injury.  Slight 
injury  sufficient  to  cause,  for  example,  a  hemorrhage  into  the 
substance  of  the  cancellous  tissue  induces  a  local  congestion  dur- 
ing the  process  of  repair  that  provides  the  proper  soil  for  the 
growth  of  the  bacilli  when  they  are  deposited  in  its  neighbor- 
hood. This  has  been  proved  experimentally  by  Krause,  and  it. 
is  supported  by  clinical  evidence.  The  great  preponderance  of 
disease  in  the  lower  over  that  of  the  upper  extremities  in  child- 
hood may  be  cited  as  evidence  of  the  influence  of  injury  in  the 
causation  of  disease. 

In  513  of  3398  cases  of  tuberculosis  of  the  bones  and  joints 
reported  by  Hildebrand,^  Koenig,  Mikulicz,  and  Bruns  injury 
seemed  to  be  a  direct  predisposing  cause  of  the  local  disease 
(16.5  per  cent.).  A  much  higher  percentage  than  this  has  been 
assigTied  by  certain  writers,  but  the  exact  relation  of  traumatism 
to  disease  can  only  be  conjectured.  For  example,  Voss"*  in  577 
cases  treated  at  Rostock  found  injury  stated  as  the  exciting  cause 

^  Archives  of  Pediatrics,  December,  1901. 
^Archiv.  de  Med.  des  Enfants,  March,  1902. 
^  Deutsche  Chir.,  1902,  L.  13,  S.  168. 
*  Zeit.  f .  Chir.,  1904,  No.  16. 


250  OBTEOPEDIC  SUBGEBY. 

in  more  than  20  per  cent.  Yet  on  further  investigation  in  but 
7  per  cent,  could  its  influence  be  clearly  established.-^ 

The  primary  disease  is  almost  always  in  the  newly  formed 
bone  on  the  epiphyseal  side  of  the  conjugal  cartilage.  This 
tissue  is  vulnerable;  it  is  more  exposed  to  direct  injury;  it  is 
subjected,  also,  to  the  strain  of  motion  at  the  neighboring  joint, 
and  as  the  circulation  is  here  more  active  the  bacilli  are  more 
often  deposited  in  this  situation. 

The  vulnerability  of  growing  bone  accounts  also  for  the 
relative  frequency  of  bone  disease  in  childhood,  as  compared 
with  adult  life.  Injury  not  only  causes  a  local  predisposition 
to  disease,  but  it  favors  its  progress  when  it  is  once  established. 

Distribution  of  the  Disease.^ — In  13,308  cases  of  tuberculous 
disease  of  the  bones  and  joints  treated  at  the  Hospital  for  Rup- 
tured and  Crippled  the  distribution  was,  in  order  of  frequency, 
as  follows : 

Vertebrae    5,662  =  42.5  per  cent. 

Hip-joint    4,048  ^  30.5  per  cent. 

Other  joints 3,598  =  27.0  per  cent. 

13^308 

In  a  total  of  3561  cases  treated  at  the  Hospital  for  Ruptured 
and  Crippled  and  at  the  Vanderbilt  Clinic  during  a  period  of 
five  years  the  distribution  was  as  follows : 

Vertebrae   1432      =  40.2  per  cent. 

Hip-joint 1123      =  31.5  per  cent. 

Knee-joint  699      =  19.6  per  cent. 

Ankle-joint   196      =    5.5  per  cent. 

Elbow-joint   62  | 

Shoulder- joint 42  I  =    3.1  per  cent. 

Wrist-joint    7  j 

3561 

Trunk 1432      =  40.2  per  cent. 

Lower  extremities   2018      =  56.6  per  cent. 

Upper  extremities Ill      =    3.1  per  cent. 

The  correspondence  between  these  two  tables  of  statistics  is 
striking,  and  the  number  of  cases  is  so  large  that  the  proportions 
may  be  accepted  as  approximately  correct  as  applied  to  the  dis- 
tribution of  the  disease  in  childhood. 

At  the  Boston  Children's  Hospital  in  a  period  of  twenty-five 
years,  1869-1893,  3820  cases  were  treated.^  The  distribution 
was  as  follows : 

^  The  literature  of  the  subject  may  be  found  in  the  Arehi\-.  f.  Orthop. 
Mechanicotherapie  u.  Unfall  C'hir.,  Bd.  iv.,  H.  4,  1906,  Deutschlander. 
-  Eeport  of  the  Boston  Children 's  Hospital. 


TUBERCULOUS  DISEASE  OF  TEE  BONES  AND  JOINTS.    251 

Vertebrae  1964      =  51.4  per  cent. 

Hip 1402      =  36.7  per  cent. 

Ankle   300      =    7.8  per  cent. 

Knee    104      =    2.7  per  cent. 

Wrist   20  "I 

Shoulder    15  [■  ^    1.3  per  cent. 

Elbow 15  j 

3820 

Trunk 1964  =  51.4  per  cent. 

Lower  extremities   1806  =  47.2  per  cent. 

Upper  extremities 50  =    1.3  per  cent. 

Side  Affected. — Disease  of  the  joints  is  slightly  more  common 
on  the  right  than  on  the  left  side  of  the  body.  At  the  Hospital 
for  Ruptured  and  Crippled  the  proportions  in  the  cases  treated 
during  a  recent  period  of  ten  years  are  as  follows : 

Hip,  right   53  per  cent. 

Knee,  right   55  per  cent. 

Ankle,  right 50  per  cent. 

Shoulder,  right   64  per  cent. 

Elbow,  right 60  per  cent. 

It  has  been  stated  that  one  of  the  explanations  of  the  great 
preponderance  of  the  disease  of  the  lower  over  the  upper  ex- 
tremity is  the  greater  liability  to  injury.  The  same  explanation 
has  been  advanced  to  account  for  the  greater  frequency  of  dis- 
ease on  the  right  side,  which  is  more  marked  in  the  upper  than 
in  the  lower  extremity,  because  the  right  arm  is  more  liable  to 
overwork  as  well  as  to  injury. 

Sex.. — Tuberculous  disease  of  the  joints  is  somewhat  more 
common  among  males  than  females. 

Of  3822  cases  of  Pott's  disease  treated  at  the  Hospital  for 
Ruptured  and  Crippled,  2037,  or  53  per  cent.,  were  in  males. 

Of  3307  cases  of  disease  of  the  hip-joint  treated  at  the  same 
institution,  1731,  or  52.3  per  cent.,  were  in  males. 

Of  1218  cases  of  disease  of  knee-joint,  combined  statistics 
of  Koenig  and  Gibney,  703,  or  57.6  per  cent.,  were  in  males. 

Age.^ — In  5461  cases  of  tuberculous  disease  treated  at  the 
Hospital  for  Ruptured  and  Crippled,  about  seven-eighths  of  the 
patients  were  less  than  fourteen  years  of  age. 

I  vertebrae,         87.7  per  cent. 

Less  than  14  years  of  age <  hip,  88.2  per  cent. 

(  other  joints,  71.7  per  cent. 

fvertebree,  7.7  per  cent, 

hip,  9.2  per  cent, 

other  joints,  10.7  per  cent. 


252 


OETHOPEDIC  SUEGEBT. 


More  than  21  years  of  age. 


i  vertebrae,  4.5  per  cent, 

hip,  2.5  per  cent, 

other  joints,  17.5^  per  cent. 

Of  1259  cases  of  Pott's  disease  treated  recently  at  the  same 
institution,  1075,  or  85  per  cent,  of  the  patients,  were  in  the 
first  decade;  50  per  cent,  were  three  to  five  years  of  age,  in- 
elusive,  at  the  inception  of  the  disease. 

In  1000  cases  of  disease  of  the  hip-joint  the  ages  of  the 
patients  correspond  closely  to  these ;  87.2  per  cent,  were  in  the 
first  decade  and  45.2  per  cent,  were  from  three  to  five  years  of 
age,  inclusive. 

In  1000  cases  of  disease  of  the  knee-joint,  75  per  cent,  were 
in  the  first  decade  and  40  per  cent,  were  from  three  to  five  years, 
inclusive. 

In  339  cases  of  the  ankle-joint,  70  per  cent,  were  in  the  first 
decade  and  but  35  per  cent,  were  included  within  the  three 
years. 

The  distribution  of  the  disease  and  its  relative  frequency  at 
the  different  ages  is  shown  by  Alfer's  table  of  statistics  from 
Trendelenburg's  clinic  at  Bonn.- 


2 

o 
1 

lO 

59 
59 

52 
9 
2 

14 
0 

195 

5 

32 

43 

47 
10 

2 
14 

0 

148 

o 
1 

LO 

23 

46 

37 

5 

6 

21 

1 

139 

S 

9 

9 
20 

2 

3 
12 

5 

60 

IM. 

10 

11 
11 

1 

5 
9 
.0 

47 

s 

3 
6 
23 
1 
3 
6 
0 

42 

o 

6 
0 
11 
3 
1 
5 
3 

29 

3 
4 
11 
2 
1 
9 
1 

31 

o 

1 

1 

3 
0 

2 
8 
3 

18 

lO 

4 
1 

2 
3 

2 
5 
2 

19 

§ 

to 

0 
3 

8 
0 
1 

2 
1 

15 

lO 

§ 

0 
0 

6 
2 
0 
2 
3 

13 

o 

0 
0 
3 
0 

0 
0 
0 

3 

"5 

o 

Vertebrae 

Hip 

Knee 

Ankle 

Shoulder 

Elbow 

Wrist 

89 
58 
47 
5 
0 
7 
1 

239 
241 

281 
43 
28 

114 
20 

Total      1  207 

966 

This  table  illustrates  the  well-known  fact  that  disease  of  the 
upper  extremity,  relatively  infrequent  at  all  ages,  is  proportion- 
ately far  more  common  in  adult  life.  Of  the  joints  of  the  lower 
extremity,  the  knee  and  the  ankle  are  proportionately  more  often 
diseased  in  later  life  than  is  the  hip. 

Pathology. — AA'heu  the  bacilli  are  deposited  in  a  part,  the 
irritation  of  their  toxins  causes  a  proliferation  of  the  fixed  cells 
which  lie  in  direct  contact  with  the  germs,  and  about  these  a 
ring  of  leukocytes  forms.  The  bacilli,  the  epithelioid  cells  in- 
cludino-  often  one  or  more  giant  cells,  together  with  the  surround- 


^  Knight.     Orthopedia. 

-Beit,    zur   klin.    Chir..   Bd.    viii.. 


IT. 


TUBERCULOUS  DISEASE  OF  TEE  BONES  AND  JOINTS.    253 

ing  leukocytes,  constitute  the  visible  tubercle  of  bone,  a  minute 
grayish  speck  in  the  cancellous  structure.  The  central  cells 
about  the  bacilli,  increasing  in  number,  deprived  of  nourishment 
and  poisoned  by  the  toxins,  die  and  are  disintegrated  to  granular 
material,  "  caseate,"  and  the  tubercle  changes  to  a  yellow  color ; 
but  the  bacilli,  multiplying  and  escaping,  form  new  tubercles 
about  the  original  focus,  which  coalesce  as  the  area  of  the  dis- 
ease enlarges.  Meanwhile,  the  surrounding  tissue  becomes  con- 
gested, as  the  result  of  the  irritation,  and  the  fixed  cells  become 
organized,  or  partly  organized,  into  a  feeble,  ill-nourished  form 
of  granulation  tissue,  representing  the  effort  of  the  part  to  shut 
out  and  to  expel  the  foreign  substances  formed  by  the  disease. 
Or,  if  this  local  resistance  is  effective,  the  cells  become  actually 
organized  into  firm  granulations  which  surround  and  destroy  the 
germs,  and  then  are  further  transformed  into  scar  tissue.  But 
in  most  instances  either  because  the  irritation  is  insufficient  or 
because  of  the  deficient  vitality  of  the  part,  the  granulations  are 
feeble  and  unstable,  and  they  in  turn  becoming  infected  by  the 
multiplying  bacilli  serve  only  to  extend  the  area  of  the  disease. 
This  granulation  tissue,  before  and  after  the  stage  of  infection, 
absorbs  and  destroys  the  bone.  If  the  progress  of  the  disease  is 
slow,  the  cancellous  structure  is  completely  absorbed  or  is  repre- 
sented only  by  bone  sand,  but  if  the  disease  infiltrates  the  bone 
more  rapidly  it  may  destroy  its  vitality  while  its  structure  is 
still  retained,  and  a  sequestrum  is  formed.  Such  sequestra, 
consisting  of  rounded,  yellow,  crumbling  masses  of  cancellous 
structure,  of  the  size  of  a  pea  or  larger,  are  especially  common 
in  epiphyseal  disease  of  childhood.  In  rare  instances  wedge- 
shaped  sequestra  are  found  with  the  base  at  the  periphery  of  the 
epiphysis.  These  are  apparently  caused  by  the  lodging  of  an 
infected  embolus  in  a  terminal  vessel,  thus  cutting  off  the  blood 
supply. 

By  the  formation  of  new  tubercles  at  the  periphery,  and  by 
the  caseation  of  material  in  the  centre  of  the  diseased  area,  a 
cavity  in  the  bone  is  formed,  containing  the  debris  of  the  granu- 
lation tissue,  often  sequestra  of  larger  or  smaller  size,  and  a 
variable  amount  of  fluid,  made  up  of  serum  and  leukocytes,  that 
has  exuded  from  the  surrounding  granulations.  The  walls  of 
this  cavity  are  formed  by  tissues  in  which  the  disease  is  active ; 
the  inner  layer  containing  the  tubercles  in  the  various  stages  of 
formation  and  decay,  the  outer,  composed  of  feeble,  ill-nour- 
ished, granulation  tissue  as  yet  not  infected,  and  beyond  this 


254  OBTHOFEDIC  SUEGHBT. 

the  softened  and  infiltrated  bone.  If  the  disease  has  ceased  to 
progress  in  any  direction  the  granulations  contain  more  blood- 
vessels, they  are  of  firmer  consistency  and  more  perfectly  organ- 
ized, and  the  substance  of  the  bone  is  harder,  showing  the 
evidence  of  repair. 

One  termination  of  epiphyseal  disease  is  by  enclosure  of  the 
focus  by  resistant  granulations,  behind  which  the  bone  solidifies 
and  shuts  in  the  disease,  or,  in  favorable  cases  in  which  its  area 
is  small,  completely  absorbing  and  replacing  it  by  scar  tissue. 

Extra-articular  Disease. — As  a  rule,  the  tendency  of  the  process 
is  to  expand  and  to  force  an  opening  through  the  cortex  of  the 
bone  to  the  exterior.  In  certain  cases  this  opening  may  form 
beyond  the  capsule  of  the  joint,  and  through  it  the  products  of 
the  disease  may  be  discharged  into  the  overlying  tissues,  form- 
ing a  tuberculous  abscess.  Here,  the  same  process  of  infection 
and  extension  of  the  area  of  disease  continues,  but  more  rapidly 
than  when  it  was  confined  within  the  bone.  The  surfaces  of  the 
muscles  and  fascia  are  infected,  and  are  covered  with  an  abscess 
membrane  of  violet  or  grayish-yellow  color,  made  up  of  tubercu- 
lous tissue  and  masses  of  fibrin,  lying  upon  and  loosely  attached 
to  the  outer  inflammatory  or  healthy  granulations. 

The  tuberculous  fluid  is  usually  of  a  thin  consistency,  com- 
posed of  serous  exudation,  leukocytes,  fibrin,  masses  of  degen- 
erated tissue,  and  fragments  of  bone  or  bone  sand.  It  is  com- 
monly of  a  whitish  color,  occasionally  reddish  from  mixture 
with  blood,  and,  in  the  later  stages,  yellow  and  serous-like.  The 
abscess  enlarges  in  the  direction  of  least  resistance,  and  in  most 
instances  finally  perforates  the  skin  by  one  or  more  openings 
through  which  its  contents  are  discharged.  Or,  its  boundaries 
may  cease  to  extend,  its  contents  may  be  absorbed,  adhesions 
may  form  between  its  walls,  and  a  spontaneous  cure  is  effected. 
Extra-articular  disease,  without  ultimate  involvement  of  the 
joint,  is  unusual.  It  is  more  common  at  those  joints  like  the 
knee,  elbow,  and  ankle,  in  which  the  bones  are  superficial ;  it  is 
very  uncommon  at  the  hip-joint,  and  it  is  practically  impossible 
in  disease  of  the  spine. 

Perforation  of  the  Joint. — Usually  the  tuberculous  process 
within  the  epiphysis,  enlarging  its  area,  comes  into  contact  with 
the  cartilage,  and  perforating  this,  finds  its  way  into  the  joint. 
While  the  disease  is  still  confined  within  the  bone,  the  tissues 
within  the  joint  are  involved  in  a  sympathetic  irritation  or 
inflammation.     The  synovial  membrane  becomes  congested  and 


TUBEBCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.    255 

hypertrophied ;  the  sjTiovial  fluid  is  increased  and  changed  in 
quality ;  fibrin  forms  and  is  deposited  upon  the  cartilage  and 
upon  the  lining  membrane  of  the  capsule.  It  is  stated  by 
Koenig  that  the  organization  of  these  fibrinous  deposits  upon 
the  cartilage  plays  an  important  part  in  its  destruction,  even 
when  actual  tuberculous  disease  is  absent.  As  a  result  of  the 
sympathetic  infiammation  within  the  joint,  adhesions  may  form 
which  may  limit  the  area  of  the  tuberculous  disease  and  retard 
its  progress  after  perforation  has  taken  place.  This  process  is 
similar  to  the  inflammatory  changes  in  the  pleura  caused  by 
underlying  tuberculous  disease  of  the  lung. 

When  the  disease  comes  into  contact  with  the  cartilage  it  dis- 
integrates ;  the  tuberculous  granulations  breaking  through  and 
spreading  over  its  surface  destroy  it  in  piecemeal,  or,  advancing 
beneath  it,  separate  it  from  the  bone  in  necrotic  fragments. 
The  synovial  membrane  becomes  thickened  and  infiltrated, 
numerous  tubercles  appear  upon  its  surface,  which  undergo  the 
secondary  changes  that  have  been  described,  and  the  joint  be- 
comes, practically  speaking,  an  abscess  cavity.  The  surfaces  of 
the  bones  are  disintegrated  by  the  disease,  and  the  destruction 
is  hastened  by  the  pressure  and  friction  due  to  muscular  spasm 
and  to  functional  use.  The  capsule,  distended  by  the  fiuid  and 
solid  products  of  the  disease,  is  usually  perforated,  and  a 
secondary  abscess,  communicating  with  it,  is  formed  in  the  sur- 
rounding tissues.  As  results  of  the  disease,  secondary  changes 
appear  in  the  neighboring  parts.  The  irritation  of  the  peri- 
osteum if  the  disease  is  of  a  quiescent  type,  may  induce  the 
formation  of  irregular  layers  of  bone  or  osteophytes  about  the 
joint,  A  new  formation  of  connective  tissue  proceeding  from 
the  layer  of  granulations  that  surround  the  disease  may  extend 
to  the  muscles  and  tendon  sheaths,  binding  them  together,  and 
causing  limitation  of  motion.  This  tissue  may  be  very  vascular 
and  irregular  in  formation,  and  intermixed  with  it  may  be 
masses  of  gelatinous  or  myxomatous  substance.  This,  according 
to  Krause,  is  due  to  the  venous  stasis  and  (Edematous  infiltra- 
tion caused  by  the  pressure  of  the  capsular  contents  and  extra- 
capsular proliferation  of  granulation  tissue.  These  changes  in 
the  appearance  and  in  the  consistency  of  the  tissues  about  the 
joint  are  characteristic  of  the  so-called  white  swelling. 

Tuberculous  disease  usually  begins  on  the  epiphyseal  side  of 
the  conjugal  cartilage.  Occasionally,  however,  it  may  appear 
primarily  on  the  diaphyseal  side  and  remain  extra-articular  or 


256  ORTHOPEDIC  SUBGEBT. 

the  shaft  may  be  involved  in  a  progressive  infiltrating  form  of 
disease  as  in  9  of  987  cases  treated  in  Bruns'  clinic.^  A  familiar 
example  is  central  disease  of  the  phalanges — "spina  ventosa  " 
■ — a  slow  infiltrating  form  of  disease  accompanied  often  by  sinus 
formation.  Distortion  and  atrophy  follow.  In  this  form  of 
disease  the  infection  is  often  multiple. 

Other  Forms  of  Tuberculous  Disease  of  Joints. — All  of  the 
German  writers  describe  forms  of  primary  synovial  disease,  its 
frequency  varying  from  16  to  35  per  cent,  of  the  cases.  It  is 
more  common  in  adult  life  than  in  childhood,  and  at  the  knee 
than  at  other  joints.  ISTichols,^  on  the  other  hand,  states  that  he 
has  examined  120  tuberculous  joints,  and  has  found  in  every 
instance  one  or  more  foci  in  the  bone  that  apparently  preceded 
the  disease  in  the  joint.  This  is  certainly  not  in  accord  with 
clinical  experience,  for  one  must  recognize  a  form  of  disease  in 
which  the  symptoms  differ  from  the  ordinary  osteal  type.  It 
begins  as  a  chronic  synovitis,  although  the  tissues  are  more 
thickened  and  infiltrated  than  in  simple  synovitis,  and  the  mus- 
cular atrophy  is  more  marked.  Eeflex  spasm  and  limitation  of 
motion  are  slight,  and  the  symptoms  are  rather  discomfort  and 
fatigue  after  exertion  than  actual  pain.  Later,  sometimes  after 
many  months,  when  it  may  be  assumed  the  bones  are  involved, 
the  characteristic  symptoms  of  tuberculous  disease  appear.  In 
one  form  of  synovial  disease  the  amount  of  effused  fluid  is  large, 
and  it  is  clear  and  serous-like  in  character — hydrops  tubercu- 
losus;  but  usually  it  is  cloudy,  and  it  may  be  purulent  in 
character. 

As  has  been  stated,  Ivoenig  lays  stress  upon  the  important 
part  played  by  fibrin  in  the  changes  that  take  place  within  a 
joint.  Fibrin  deposited  from  the  effused  fluid  forms  in  suc- 
cessive layers  upon  the  cartilage.  Into  this  fibrin  vessels  grow 
from  the  hypertrophied  and  infected  synovial  membrane,  de- 
stroying the  cartilage  together  with  the  underlying  bone.  If  the 
synovial  disease  is  primary  the  erosion  of  bone  is  superficial  as 
contrasted  with  the  ordinary  osteal  type.  Synovial  tuberculosis 
is  essentially  a  subacute  chronic  affection  and  it  is  therefore 
often  mistaken  for  traumatic  or  so-called  rheumatic  synovitis. 

Arborescent  Synovial  Tuberculosis. — In  this  form  the  interior 
of  the  joint  is  covered  with  villous  proliferations  of  the  s\movial 
membrane.     It  is  not  a  distinct  disease,  but  is  an  irritative  hy- 

'  Zumsteeg,  Beit.  zur.  klin.  CMr.,  B.  50,  H.  1,  1906. 
2  Transactions  American  Orthopedic  Association,  vol.  xi. 


TUBEBCULOVS  DISEASE  OF  THE  BONES  AND  JOINTS.    257 

pertrophy  that  is  present  in  syphilitic  and  rheumatic  as  well  as 
in  tuberculous  joints.  Its  especial  interest  lies  in  the  fact  that 
the  hypertrophied  synovial  growths  may  cause  mechanical  inter- 
ference with  the  function  of  the  joint. 

Arborescent  villous  proliferations  are  formed  of  adipose  and 
fibrous  tissue  covered  with  a  layer  of  round  cells.  The  hyper- 
trophied masses  which  project  into  the  joint  are  often  of  large 
size  (lipoma  arborescens),  attached  to  the  synovial  membrane 
by  a  smaller  pedicle.     They  are  single  or  multiple,  and  vary  in 

Fig.  182. 


Lipoma  arborescens.      (Paiutei*  and  Erving.) 

color  from  yellow  to  deep  red.  They  may  be  of  a  soft  or  firm 
consistency.  In  this  form  of  disease,  there  is  usually  pain, 
limitation  of  motion;  often  the  swollen  joint  is  irregular  in 
outline ;  the  hypertrophied  synovial  prolongations  are  some- 
times apparent  on  palpation.^  The  exact  diagnosis  is  usually 
made  only  after  an  exploratory  incision,  and  in  such  an  event 
the  removal  of  the  larger  growths  would  be  indicated.  The 
outcome  depends,  of  course,  upon  the  cause,  the  hypertrophy 
depending  usually  on  an  underlying  tuberculous,  syphilitic,  or 
other  chronic  disease.  In  the  instances  in  which  the  hyper- 
trophied tissue  is  in  itself  the  cause  of  the  disability  by  inter- 
ference with  function,  relief  may  follow  its  removal. 

Rice  Bodies.— Rice  bodies  are  small,  grayish-white  bodies  .re- 
sembling cucumber  seeds  .that  are  found  in  certain  forms  of 
synovial   disease,    and   particularly   in   tuberculosis    of   tendon 

^  Painter  and  Erving,  Boston  Med.  and  Surg.  Journal,  March  19,  1903. 
17 


258  OBTHOPEDIC  SUBGEBY. 

sheaths.  They  are  formed  of  fragments  detached  from  the 
proliferating  synovial  membrane  and  possibly  of  simple  fibrin, 
which,  under  the  influence  of  pressure  and  attrition  in  the 
movements  of  the  joint  or  of  the  tendon,  assume  the  char- 
acteristic shape  and  appearance.  These  bodies,  within  a  tendon 
sheath  or  joint,  cause  a  peculiar  creaking,  perceptible  to  the 
touch  when  the  part  is  moved. 

Dry  Caries  (Caries  8icca). — In  this  form  of  disease,  which 
is  apparently  primarily  synovial,  there  is  but  little  formation  of 
fluid,  and  there  is  but  little  tendency  toward  cheesy  degenera- 
tion of  the  tuberculous  products.  The  infected  granulations 
destroy  the  bone  without  forming  sequestra,  and  usually  without 
suppuration.  This  form  more  often  occurs  at  the  shoulder-joint, 
and  it  is  characterized  by  marked  limitation  of  motion,  extreme 
atrophy  of  the  surrounding  parts,  and  sometimes  by  forward 
displacement  of  the  partly  destroyed  head  of  the  humerus  that 
may  be  mistaken  for  a  primary  dislocation. 

Septic  Infection. — After  a  tuberculous  abscess  has  opened 
spontaneously,  or  if  it  has  been  incised,  infection  with  pyogenic 
germs  is  common,  and  it  occasionally  occurs  before  a  communi- 
cation with  the  exterior  has  been  established. 

After  such  infection  the  surrounding  tissues  become  infil- 
trated, reddened,  and  sensitive  to  pressure.  The  discharge  is 
greatly  increased  in  quantity  and  changed  in  quality.  The 
local  pain  and  discomfort  are  aggravated;  if  the  joint  is  in- 
volved the  destruction  of  the  bone  goes  on  with  increased  rapid- 
ity, and  the  constitutional  effects  of  pyogenic  infection  appear. 
If  the  area  of  the  abscess  is  small  and  if  the  drainage  is  efficient, 
this  accident  is  of  slight  importance,  and  it  may  even  exercise 
a  beneficial  effect  in  stimulating  the  circulation  and  dissolving 
the  eifused  material  about  a  joint.  But  if  the  abscess  has  bur- 
rowed widely  into  surrounding  tissues  and  if  it  communicates 
with  an  important  joint  it  is  a  dangerous  complication;  in  fact, 
the  greatest  direct  danger  of  tuberculous  joint  disease.  Per- 
sistent suppuration  exhausts  the  patient,  and  by  lessening  the 
vital  resistance  it  favors  the  local  advance  of  the  tuberculous 
disease  and  its  general  dissemination.  It  is  in  this  class  of  cases 
that  amyloid  degeneration  of  the  internal  organs  is  common, 
induced  not  by  tuberculous  disease,  but  by  the  secondary  infec- 
tion and  its  consequences. 

Repair. — Repair  in  tuberculous  disease  may  be  accomplished 
by  the  absorption,  ejection,  or  enclosure  of  the  disease.     The 


TUBEBCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.    259 

process  of  repair  usually  accompanies  the  advance  of  the  de- 
structive process,  and  examples  of  the  three  methods  of  cure 
may  be  found  in  a  single  joint. 

The  curative  agent  is  the  granulation  tissue  which  forms 
about  the  area  of  disease,  and  which,  finally  becoming  suffi- 
ciently organized  to  resist  the  infection  of  the  bacilli,  solidifies 
into  fibrous  tissue.  In  those  cases  in  which  the  disease  is  not 
absorbed  or  completely  thrown  off  in  the  abscess  formation,  but 
is  enclosed,  it  becomes  quiescent.  In  such  cases  traumatism, 
when,  for  example,  the  surrounding  adhesions  are  broken  down 
in  the  attempt  to  rectify  deformity  or  to  overcome  anchylosis, 
may  cause  local  recurrence  of  the  disease. 

Prognosis. — The  prognosis  will  be  considered  more  particu- 
larly in  the  sections  on  disease  of  special  parts.  The  danger  to 
life  is  direct  and  indirect,  and  this  varies  greatly  with  the  part 
that  is  affected  and  with  the  age  of  the  patient. 

In  disease  of  the  spine  the  direct  danger  to  life  is  greater 
than  in  joint  disease,  because  of  its  situation,  since  it  may  in- 
volve the  spinal  cord  or  extend  to  the  important  organs  in  the 
neighborhood.  Abscess  may  in  rare  instances,  merely  by  its 
size  and  situation,  endanger  life,  and  when  infected  it  is  far 
more  dangerous  because  of  the  difficulty  in  providing  efficient 
drainage.  The  influence  of  deformity  and  its  effect  in  com- 
pressing the  internal  organs  and  thus  interfering  with  the  vital 
functions  is  another  more  remote  element  of  danger  in  disease 
in  this  situation. 

The  danger  to  life  from  disease  of  the  joints  is  in  proportion  to 
their  importance.  In  rare  instances  the  disease  may  extend  from 
the  epiphysis  to  the  shaft  of  a  bone  and  set  up  an  extensive  osteo- 
myelitis; or  the  patient  may  be  weakened  by  the  suffering 
caused  by  active  disease,  but,  as  has  been  stated,  the  most  direct 
and  constant  danger  is  from  prolonged  suppuration  that  follows 
septic  infection.  Danger  from  this  source  is  much  greater  at 
the  hip-joint  than  at  the  ankle  or  elbow,  for  example,  because 
of  the  greater  difficulty  in  preventing  the  burrowing  of  pus  when 
infection  has  occurred. 

The  indirect  danger  of  tuberculous  disease  is  its  dissemina- 
tion to  more  important  organs.  But  it  by  no  means  follows  that 
the  disease  of  the  joint  is  the  source  of  the  general  infection. 
For,  as  has  been  stated,  it  may  be  inferred  that  nearly  every 
patient  with  joint  disease  has  also  disease  of  the  lymphatic 
glands,  and  in  a  certain  proportion  of  the  cases  there  may  be 


260  OETHOPEDIC  SUBGEBY. 

active  disease  of  other  important  organs  as  well.  Tuberculosis 
of  the  lungs,  for  example,  is  often  present  in  the  adult  before 
the  local  outbreak  in  the  joint  appears,  and  it  is  in  great  degree 
because  of  this  liability  to  disease  of  the  lungs  that  the  prognosis 
of  joint  disease  becomes  progressively  worse  with  the  age  of  the 
patient. 

This  point  is  illustrated  by  the  statistics  of  Koenig  and  Bruns 
on  the  final  results  of  disease  of  the  knee-  and  hip-joints,  to 
which  attention  will  be  called  again  in  the  special  sections.  In 
Koenig' s  cases  of  disease  of  the  knee-joint  the  influence  of  age 
upon  the  death-rate  is  illustrated  by  the  following  table : 

Less  than  15  years  of  age 20  per  cent. 

From   16   to    30   years 24  per  cent. 

From  30  to  40  years 44  per  cent. 

More  than  40  years 60  per  cent. 

In  Bruns'  statistics  the  death-rate  was  of  patients  in  the  first 
decade,  36  per  cent. ;  in  the  second  decade,  44  per  cent. ;  older 
than  this,  72  per  cent. 

The  cure  of  latent  tuberculosis  in  the  lymph  nodes  as  well  as 
of  active  disease  of  the  lungs  or  bones  depends  upon  the  vital 
resistance  of  the  patient.  This  vital  resistance  is  lessened  by 
pain,  by  confinement  and  lack  of  exercise.  It  is  directly  im- 
paired by  the  exhausting  suppuration  and  by  the  poisoning  of 
the  toxins  incidental  to  septic  infection.  Under  these  conditions 
the  local  disease  advances  and  a  general  dissemination  is  more 
probable.  This  accounts  for  the  fact  that  death  from  general 
tuberculous  infection  is  far  more  common  in  this  class  than 
when  suppuration  has  been  slight  or  absent.  This  point  is  again 
illustrated  by  the  statistics  referred  to.  The  death-rate  in  the 
cases  of  disease  at  the  knee  without  abscess  was  25  per  cent., 
with  abscess  46  per  cent.  Death-rate  in  cases  of  disease  at  the 
hip  with  abscess  52  per  cent.,  without  abscess  23  per  cent. 

It  is  probable  that  tuberculosis  may  be  disseminated  by  opera- 
tion upon  tuberculous  joints,  although  the  evidence  upon  this 
point  is  vague  and  conflicting.  Gibney,  contrasting  two  equal 
periods  of  thirteen  years  of  service  at  the  Hospital  for  Ruptured 
and  Crippled,  in  the  first  of  which  no  operations  were  performed 
on  tuberculous  subjects,  states  that  in  his  opinion  the  deaths 
from  this  source  have  been  proportionately  no  greater  during 
the  period  of  active  surgical  intervention  than  before.  And  an 
investigation  of  the  causes  of  deaths  among  the  patients  treated 
at  the  jSTew  York  Orthopedic  Dispensary  and  IIosj)ital  during 


TUBEBCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.    261 

a  period  of  twenty  years  showed  that  at  least  25  per  cent,  of 
these  were  due  to  tuberculous  meningitis.-^  During  this  period 
there  had  been,  practically  speaking,  no  operative  intervention, 
yet  the  proportion  of  deaths  from  this  cause  is  certainly  as  great 
as  in  any  statistics  that  have  been  reported.  It  would  appear, 
then,  that  the  danger  of  dissemination  is  not  sufficient  to  deter 
one  from  performing  any  operation  that  seems  to  be  indicated 
by  the  character  of  the  local  disease  or  by  the  general  condition 
of  the  patient. 

Diagnosis.- — Diagnosis  is  considered  at  length  in  the  sections 
on  diseases  of  the  special  joints.  Of  the  tuberculin  tests  the 
direct  injection  is  the  most  reliable.  This  is  valuable  from  the 
negative  standpoint,  but  less  so  as  establishing  a  diagnosis  of 
joint  disease,  for  the  reason  that  tuberculous  disease  of  the 
lymph  glands  is  so  common  even  among  those  whose  joints  are 
free  from  disease.  For  the  same  reason  it  is  valueless  as  a  test 
of  practical  cure.  This  is  illustrated  by  the  investigations  of 
Frazier  and  Biggs^  of  patients  clinically  cured  of  local  tuber- 
culosis, some  by  operative  means.  In  78  per  cent,  of  these  a 
positive  reaction  to  tuberculin  was  obtained.  In  some  instances 
however,  a  local  reaction  may  indicate  foci  of  disease  whose 
presence  would  not  otherwise  have  been  suspected. 

Tinker,  who  has  reported  a  series  of  four  hundred  tests  from 
Johns  Hopkins  Hospital,  states  that  healthy  individuals  react 
if  the  dose  is  sufficiently  large.  One,  therefore,  begins  with 
small  injections,  from  1  to  3  milligrams  of  Koch's  old  tuber- 
culin. This  may  be  increased  to  9  milligrams,  a  reaction  to 
less  than  this  amount  being  practically  positive  if  the  tempera- 
ture of  the  patient  taken  at  intervals  of  two  hours  for  at  least 
eighteen  hours  has  been  normal.  The  reaction  appears  in  fromi 
six  to  eight  hours. 

The  X-ray  is  often  of  value  in  demonstrating  the  effects  of 
disease,  and  in  certain  instances  it  may  indicate  its  exact; 
locality  and  extent.  As  a  means  of  early  diagnosis  of  joint; 
disease  in  young  subjects,  however,  it  is  of  little  importance  as. 
compared  to  the  physical  signs,  because  of  the  non-development 
of  the  bony  structure  of  the  epiphysis,  which  alone  appears  in: 
the  negative. 

Treatment.^ — -From  what  has  been  stated  of  the  causes  of  dis- 
ease it  follows  that  the  general  treatment  should  include,   i£ 

^  Personal  communication  from  Dr.  David  Bovaird. 
^  University  Medical  Magazine,  February,  1901. 


2^52 


OBTEOPEDIC  SUBGEBY. 


possible,  a  change  in  the  hygienic  conditions,  relief  from  the 
danger  of  further  infection,  pure  air,  and  proper  food.  These 
are  as  essential  in  the  treatment  of  tuberculosis  of  the  bones  as 
of  other  parts. 

The  importance  of  the  constitutional  treatment  of  tuberculous 
disease,  more  particularly  the  proper  environment  in  which  the 
greater  part  of  the  day  and  even  the  night  may  be  passed  in  the 
open  air,  can  hardly  be  exaggerated. 

As  far  as  the  cure  of  local  disease  is  concerned,  no  treatment 
can  be  as  effective  as  the  prompt  and  thorough  removal  of  the 
focus  of  disease,  while  it  is  yet  limited  in  extent,  and  before  the 
joint  has  become  involved.  This  is  practicable,  however,  in  but 
a  small  proportion  of  the  cases  in  childhood,  because  it  is  usually 
impossible  to  .locate  the  disease  accurately  and  impossible  to 
remove  it  without  sacrificing  normal  bone  upon  which  the  future 
usefulness  of  the  part  depends.  At  one  time  early  operation^ 
even  complete  excision  of  the  joint,  was  justified  on  the  plea 
that  the  disease  might  thus  be  eradicated.  But  now  that  it  is 
known  that  in  nearly  all  cases  other  tuberculous  foci  exist  in  the 
body,  and  as  the  functional  results  after  these  early  operations 
are  far  inferior  to  those  attained  under  conservative  treatment, 
early  excisions  are  limited  to  the  adolescent  or  adult  cases.  For 
in  this  class  growth  has  been  attained  and  the  economic  condi- 
tions require  that  the  period  of  disability  should  be  as  short  as 
possible.  In  this  class,  also,  early  exploratory  operations  are 
often  indicated,  sometimes  for  the  purpose  of  establishing  the 
diagnosis,  and  if  the  disease  is  of  the  synovial  type  the  removal 
of  projecting  folds  of  hypertrophied  tissue  and  the  direct  appli- 
cation of  irritants,  for  example,  of  pure  carbolic  acid,  may  be 
of  service.  Brace  treatment  is  conducted  with  the  aim  of  reliev- 
ing the  part  of  function — that  is  to  say,  from  strain  and  injury. 
Timctional  use  of  a  diseased  joint  delays  natural  repair,  since 
it  causes  pain  and  thus  reduces  the  reparative  force,  while  it 
stimulates  the  disease  and  increases  its  destructive  action.  The 
details  of  treatment  will  be  described  in  the  consideration  of 
disease  of  special  joints. 

Drugs. — The  administration  of  drugs  oectipies  a  very  sub- 
ordinate place  in  treatment,  since  it  is  not  believed  that  any 
drug  exercises  a  direct  action  upon  the  local  disease  in  the  bone. 

Cod-liver  oil,  the  hypophosphites,  the  various  preparations  of 
iron  or  other  tonics  may  be  given  at  certain  times  with  benefit, 
btit  the  continuotis  administration  of  medicine  dtiring  the  years 


TUBEBCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.    263 

that  are  required  to  complete  a  cure  is,  of  course,  out  of  the 
question. 

Local  Applications.. — Iodoform. — Iodoform  is  supposed  to  ex- 
ercise a  direct  germicidal  action  and  also  to  stimulate  the  forma- 
tion of  the  granulations  that  cast  qff  or  absorb  the  tuberculous 
products  and  then  become  transformed  into  fibrous  tissue.  Its 
use  is  now  practically  limited  to  the  treatment  of  tuberculous 
abscesses  and  certain  forms  of  synovial  tuberculosis.  Iodoform 
is  ordinarily  employed  in  an  emulsion  with  glycerin  or  oil,  10 
c.c.  of  10  per  cent,  mixture  being  injected  at  intervals  of  two  or 
more  weeks  after  aspiration.  Several  deaths  from  iodoform 
poisoning  have  been  reported,  but  injections  of  this  quantity  of 
the  drug  are  apparently  free  from  danger. 

Calot's  fluids : 

Xo.  1. 

Sterilized  oil 70  gm. 

Ether   30  gm. 

Creosote   6  gm. 

Iodoform    10  gm. 

Xo.   2. 

Camphorated  naphthol    2  grams. 

Glycerine    10  grams. 

To  be  mixed  in  a   mortar  and  used  immediately. 

These  mixtures  are  interchangeable  but  the  first  is  preferred 
if  the  contents  of  the  abscess  are  liquid  ("ripe"),  the  second 
when  the  products  of  disease  are  but  partly  broken  down.  The 
dose  of  each  is  from  2-12  grams  repeated  at  intervals  of  a  week 
or  more;  10  or  more  injections  being  employed  in  the  treatment 
of  the  ordinary  case. 

Iodoform  FiLLi]srG  for  Boxe  Cavities. — V.  Mosetig-Moor- 
hof^  uses  a  mass  made  up  of  finely  powdered  iodoform  60  parts, 
spermaceti  and  oil  of  sesamum  20  parts  each.  The  mixture, 
which  becomes  fluid  at  50°  C,  is  thoroughly  stirred  before 
using.  The  cavity  in  the  bone  having  been  made  absolutely 
dry  is  filled  with  the  fluid,  which  solidifies  as  the  temperature 
is  lowered.  The  wound  is  then  closed.  The  filling  is  slowly 
absorbed,  its  object  being  to  preserve  the  contour  of  the  bone. 
In  a  series  of  220  cases  reported  by  this  author  no  local  dis- 
turbance followed  the  procedure. 

Beck's  Preparation. — E.  G.  Beck  uses  for  injection,  bismuth 
and  vaseline  in  proportion  of  1—3.  The  mixture  is  made  while 
the  vaseline  is  boiling  and  is  injected  at  a  temperature  of  110°. 
A  suflicient  quantity  is  used  to  distend  the  abscess  cavity  and 

'  Deutsche  Zeitsch.  f .  Chir.,  vol.  Ixxi.,  No.  5. 


264  OETEOPEDIC  SUBGEBY. 

thus  to  exercise  a  certain  degree  of  mechanical  pressure.  In 
the  process  of  absorption  it  is  assumed  that  nitric  acid  is  set 
free  and  that  a  germicidal  action  is  thus  exerted.  To  fill  the 
abscess  cavity  a  large  quantity  of  the  mixture  may  be  required 
and  the  injection  must  be  repeated  at  intervals.  Many  cases 
of  poisoning  of  a  mild  type  have  been  recorded  and  several 
deaths — one  from  the  injection  of  as  small  an  amount  as  six 
ounces. 

Beck's  mixture  v^^as  originally  used  for  the  purpose  of  demon- 
strating the  situation  and  extent  of  abscesses  and  sinuses  by 
X-ray  pictures  and  for  this  purpose  it  is  of  value  aside  from  its 
therapeutic  action.     See  Sinuses. 

Caebolic  Acid.- — Carbolic  acid  in  dilute  solutions  was  at  one 
time  injected  into  tuberculous  cavities,  but  its  use  has  been  gen- 
erally discontinued  because  of  the  danger  of  poisoning.  Recently 
Phelps  has  advocated  the  use  of  pure  carbolic  acid  in  the  treat- 
ment of  tuberculous  abscesses  and  sinuses.  This  is  injected  into 
the  fistulas  or  into  the  abscess  cavity,  w^hich  has  been  opened, 
and  is  allowed  to  remain  for  about  a  minute,  when  it  is  neu- 
tralized by  copious  injections  of  alcohol,  after  which  the  part  is 
thoroughly  cleansed  by  salt  solution.  Carbolic  acid  doubtless 
acts  as  a  caustic,  destroying  the  infected  granulations  and  stimu- 
lating the  reparative  processes.  Other  remedies  of  this  class, 
for  example  tincture  of  iodine,  chloride  of  zinc,  actual  cautery 
and  the  like,  are  also  used,  and  in  certain  cases  with  benefit.  In 
the  treatment  of  tuberculous  ulcerations  ichthyol,  balsam  of 
Peru,  and  iodoform  are  among  the  drugs  employed.  Balsam 
of  Peru  dissolved  in  castor  oil  of  a  strength  of  about  10  per 
cent.,  as  suggested  by  Van  Arsdale,^  is  a  very  satisfactory  ap- 
plication. 

X-rays. — The  X-ray  as  a  local  treatment  appears  to  act  as  a 
stimulant  of  the  reparative  processes.  It  is  of  especial  value  as 
an  adjunct  in  the  cases  in  which  the  tissues  about  the  joint  are 
infiltrated  and  traversed  by  discharging  sinuses.  The  exposure 
of  the  diseased  tissues  to  the  direct  rays  of  the  sun  is  certainly 
a  harmless  treatment,  and  it  should  be  aj^plied  if  occasion  offers. 

Active  and  Passive  Congestion  (Bier's  Hyperaemia). — Bier's 
treatment  of  tuberculous  joint  disease  was  suggested  by  the 
observation  of  Rokitansky,  that  phthisis  was  uncommon  in 
individuals  suffering  from  disease  of  the  heart  when  the  mechan- 
ical obstruction  was  sufficient  to  cause  venous  congestion  of  the 

lungs. 

'  Am.  Med.  Assn.,  March  14,  1908. 


TUBEBCULOUS  DISEASE  OF  TEE  BONES  AND  JOINTS.    265 

Passive  Congestion. — Passive  or  venous  congestion  of  a 
joint  is  attained  by  constricting  the  limb  with,  several  circular 
turns  of  a  soft  rubber  bandage  above  the  affected  joint  suffi- 


FiG.  183. 


Fig.  184. 


The  alcohol  lamp  and  chimney. 
Used  for  active  congestion.    (Bier.) 


The  application  of  passive  congestion : 
A,  the  alternate  point  for  the  applica- 
tion of  the  bandage,  in  order  to  avoid 
atrophy  from  continuous  pressure.  Bj 
the  rubber  bandage.      (Bier.) 


cientlj  to  interfere  with  the  return  of  the  venous  blood,  but  not 
with  the  arterial  supply. 

The  congestion  may  be  localized  if  desirable  by  bandaging 
the  limb  firmly  with  flannel  or  other  somewhat  elastic  material 
up  to  the  lower  margin  of  the  joint.  This  is  however  not 
essential  and  in  treating  disease  of  the  upper  extremity  in  which 
the   finger  joints   are   stiffened   or  in  which   the   muscles   are 


266  OBTHOPEDIC  SUEGEBY. 

atrophied  and  contracted,  the  congestion  of  the  entire  extremity 
is  indicated.  When  properly  applied  the  joint  becomes  swollen 
and  dark  red  in  color.  The  local  temperature  is  raised.  This 
is  what  Bier  calls  hot  congestion,  as  distinct  from  oedema  (cold 
congestion),  that  would  result  if  the  rubber  bandage  were  ap- 
plied so  tight  as  to  constrict  the  arteries.  Passive  congestion 
should  not  cause  or  increase  pain.  If  it  has  this  effect  it  is 
improperly  applied  or  is  unsuitable  for  the  case  (Fig.  183). 

The  api^lication  should  be  limited  to  one  to  three  hours  daily 
in  one  or  several  periods  according  to  the  effects. -"^ 

The  action  of  the  venous  or  passive  congestion  is,  according 
to  Bier,  as  follows : 

1.  It  increases  the  fonnation  of  fibrous  tissue  and  induces 
hypertrophy  of  the  bones. 

2.  It  has  a  bactericidal  action  in  infectious  joint  disease, 
notably  tuberculosis.^ 

3.  It  exercises  an  absorptive  effect  on  the  effused  products  of 
disease  and  on  new  formations  that  check  joint  motion. 

4.  It  relieves  pain  and  lessens  the  activity  of  progressive  joint 
disease. 

Passive  congestion  for  tuberculous  joint  disease  should  be  sub- 
ordinated to  protective  treatment,  although  this  is  not  the 
opinion  of  Bier,  who  favors  motion  rather  than  fixation  of  the 
diseased  joint.  It  may  be  continued  indefinitely  according  to 
its  effect.  As  a  rule,  pain  is  lessened  by  the  treatment  and 
muscular  spasm  decreases.  This  latter  effect  is  in  part,  at  least, 
explained  by  the  constriction  of  the  muscles. 

Abscess  formation  or  appearance  at  least  is  apparently 
favored  by  the  congestion.  This  may  be  treated  by  aspiration 
(^r  incision  and  by  the  injection  of  the  iodoform  emulsion  if 
desirable. 

Passive  congestion  is  employed  also  for  the  treatment  of 
chronic  disability  following  injury,  for  chronic  arthritis  or 
other  affection  attended  by  infiltration  of  tissues  and  by  defi- 
cient circulation.  In  this  class  of  cases  the  local  congestion 
should  be  combined  with  massage.  Local  congestion  may  be 
attained  by  Klapj^'s  suction  appliances  on  the  principle  of 
cupping.  This  method  may  be  employed  with  advantage  in  the 
treatment  of  sinuses   and  cavities  which  cannot  be   properly 

^  Bier,  Hyperamie  als  Heilmittel,  Leipzig,  1905,  and  Schmieden,  Med. 
Eecord,  Aug.  17,  1907. 

^Gratt,  Berlin,  klin.  Woehen.,  Feb.   10,  1908. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.    267 

drained  and  for  the  immediate  evacuation  of  pus  through  a 
small  incision. 

The  treatment  of  acute  infectious  processes  of  joints  and 
other  tissues  by  passive  congestion  has  now  come  into  general 
use.     Bardenheuer  is  one  of  its  most  enthusiastic  advocates.-^ 

Active  CoNGESTioisr. — Active  congestion  is  induced  by  the 
local  use  of  heat,  ordinarily  hot  dry  air. 

In  its  simplest  form  the  apparatus  consists  of  an  alcohol  lamp 
provided  with  a  long  metal  chimney  reaching  to  a  box  of  wood 
or  metal,  into  which  the  limb  is  inserted  through  openings  at 
either  end.  The  box  has  one  or  more  small  openings  for  the 
escape  of  air  and  moisture.  The  limb  is  usually  wrapped  in 
sheet  wadding,  and  is  particularly  well  protected  from  the  parts 

Fig.  185. 


The  application  of  ttie  liot-air  box  for  inducing  active  congestion.  The  box. 
Oj  the  thermometer.  A,  a  metal  pipe  projecting  from  the  box,  into  which  the 
chimney  of  the  lamp  is  placed.     B^  lamp  chimney.      (After  Bier.) 


of  the  box  which  may  come  in  contact  with  the  skin.  The  heat 
is  then  applied,  usually  to  about  250°  or  300°  F.,  for  from 
thirty  minutes  to  an  hour  daily.  The  degree  of  heat  is  indicated 
by  a  projecting  thermometer,  and  it  is  regulated  by  the  comfort 
of  the  patient  and  by  the  observation  of  its  effects. 

Bier  prefers  simple  boxes  of  wood  of  various  shapes  suitable 
for  the  different  parts  of  the  body,  lined  with  packing  cloth 
soaked  in  a  solution  of  water  glass.  He  considers  these  as 
efficacious  as  the  complicated  and  expensive  appliances,  and  at 
the  command  of  all  who  desire  to  employ  the  treatment 
(Fig.  185). 

^  Deutschen  f .  Chir.,  XXXV.  Kongress,  1906. 


268  OBTHOPEDIC  SURGEBY. 

The  effect  of  the  heat  is  to  induce  arterial  instead  of  venous 
hypersemia,  and  to  cause  profuse  local  and  general  perspiration. 
Active  hypersemia  is  not  suitable  for  the  treatment  of  acute  or 
progressive  joint  disease.  It  exercises  a  dissolving  and  absorb- 
ing action  on  effused  material  and  on  the  tissues  of  new  forma- 
tion causing  limitation  of  motion  within  a  joint.  It  increases 
local  nutrition  and  it  relieves  pain.  It  is  especially  indicated  in 
the  treatment  of  local  disability  after  injury,  chronic  effusions 
into  joints,  chronic  arthritis,  and  the  like  in  which  the  circula- 
tion is  deficient. 

As  a  rule,  the  application  of  local  heat  should  be  supple- 
mented by  massage.  The  profuse  general  perspiration  that  is 
induced  by  it  is  a  contraindication  in  weak  individuals. 


CHAPTEE  VI. 
NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS. 

SYPHILITIC   DISEASES   OF   THE   JOINTS. 

Iisr  early  infancy  the  characteristic  manifestations  of  con- 
genital syphilitic  disease  of  the  bones  is  a  form  of  osteochondri- 
tis. Sensitive  swellings  appear  at  the  epiphyseal  junctions, 
either  as  small,  hard  tumors  or  as  general  enlargements,  re- 
sembling those  of  rhachitis  (Fig.  186).  As  a  rule,  several 
epiphyses  are  involved,  more  often  those  at  the  distal  extremities 
of  the  bones  of  the  lower  limbs,  and  in  these  cases  the  pain  and 
discomfort  may  induce  an  appearance  of  helplessness  of  the 
part  called  pseudoparalysis  (Parrot). 

In  osteochondritis  there  is  a  multiplication  and  irregularity 
of  the  cartilage  cells  of  the  ossifying  layer  and  premature  calci- 
fication. ISTecrosis  may  result  as  showa  by  a  zone  of  hard,  dry, 
yellow  substance  in  the  ossifying  layer  of  the  cartilage,  about 
which  newly  formed  bone  is  softened  and  in  part  replaced 
by  granulation  tissue.  If  the  disease  is  progressive,  ulceration 
and  suppuration  may  follow;  the  cartilage  may  be  destroyed, 
and  the  epiphysis  may  be  separated,  causing  deformity  and 
cessation  of  growth.  The  neighboring  joint  is  usually  involved 
in  the  disease.  In  the  milder  cases  there  is  a  simple  sympathetic 
synovitis ;  in  the  advanced  class  a  destructive  arthritis.  In  one 
case  seen  recently  in  a  child  three  months  of  age  the  symptoms 
of  pain  on  motion  combined  with  slight  effusion  into  several 
joints  were  present  without  the  epiphyseal  enlargement.  The 
affection  may  be  distinguished  from  rhachitis  by  the  accompany- 
ing evidences  of  inherited  syphilis,  by  the  irregularity  of  the 
epiphyseal  enlargements,  and  by  the  age  of  the  patient  and  the 
absence  of  the  other  symptoms  of  rhachitis. 

In  the  later  manifestations  of  hereditary  syphilis,  in  which 
th^  bones  in  the  neighborhood  of  the  joint  are  involved  in 
syphilitic  osteoperiostitis,  the  joint  may  be  sympathetically 
affected  or  the  disease  may  actually  perforate  the  joint.  In  this 
form  of  disease  the  synovial  membrane  is  usually  hypertrophied 
to  such  degree  as  to  interfere  with  the  function  of  the  joint. 
The  fluid  is  increased  in  quantity  and  the  affection  may  resem- 

269 


270 


OBTHOPEDIC  SUBGEEY. 


ble  synovial  tuberculosis.  A  slow,  chronic,  infiltrating  gum- 
matous form  of  disease  appearing  in  later  childliood  may  simu- 
late very  closely  the  appearances  of  so-called  white  swelling.  It 
is  more  common  at  the  knee,  but  other  joints  are  often  affected 
as  well.  In  other  instances  one  or  more  of  the  joints  may  be 
involved  before  the  enlargement  of  the  neighboring  bone  is  ap- 
parent, the  symptoms  being  those  of  chronic  synovitis. 

Fig.  186. 


Suppurative  syphilitic  epiphysitis  at  lower  ends  of  radius  and  tibia  in  an 
infant  aged  one  month.  The  child  died  shortly  after  the  drawings  were  made, 
and  the  epiphyses  were  found  lying  loose  in  purulent   cavities.      (Tubby.) 

In  tertiary  syphilis  the  joint  may  be  invaded  by  disease  in  the 
neighboring  bones,  or  the  joint  itself  may  be  primarily  im- 
plicated. 

There  is  general  thickening  of  the  synovial  membrane,  effu- 
sion and  later  destruction  of  cartilage.  Pain  is  as  a  rule  not 
severe.^ 

The  joint  manifestations  of  acquired  syphilis  are  pain,  most 
marked  at  night,  during  the  exanthematous  stage.  In  some 
instances  effusion  may  be  present  which  if  persistent  may  be 
accompanied  by  hypertrophy  of  the  synovial  membrane.  The 
knee,  shoulder  and  elbow  joints  are  most  often  involved. 

'  Bona,  Berlin,  klin.  Woch.,  n.  43  and  44,  1907. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.  271 

The  diagnosis  of  syphilitic  joint  disease  is  usually  suggested 
by  the  history  and  is  confirmed  by  the  other  signs  of  syphilitic 
disease.  The  most  important  of  the  confirmatory  signs  of 
hereditary  syphilis  is  keratitis.  In  a  series  of  77  cases  in  which 
this  was  present  there  was  involvement  of  the  joints  in  56  per 
cent.,  the  knee  being  most  often  affected.^  Spina  ventosa  (Fig. 
188),  which  is  classed  as  one  of  the  evidences  of  syphilis,  is  far 

Fig.  187. 


Syphilitic  osteoperiostitis  of  ttie  tibiae  resembling  anterior  bow-leg.  This  is 
the  most  characteristic  manifestation  of  hereditary  syphilis.  It  induces  not 
only  deformity  and  hypertrophy,  but  elongation  of  the  bones  as  well. 

more  commonly  of  tuberculous  origin^  as  is  illustrated  by  the 
statistics  of  Karewski,^  of  157  cases,  in.  which  but  three  were 
due  to  syphilis. 

Syphilitic  disease  of  the  joints  is  comparatively  rare  in  ortho- 
pedic clinics   as  contrasted  with  those  of  tuberculous   origin. 

^Hippel,  Miinch.  med.  Woch.,  No.  31,  1903. 
-  Chir.  Krank.  dies  Kindesalters. 


272 


OBTHOPEDIC  SUEGEBY. 


This  is  as  migiit  be  expected,  for  not  only  is  tuberculosis  far 
more  common  than  syphilis,  but  a  very  large  proportion,  accord- 
ing to  Fournier,  77  per  cent.,  of  the  syphilitic  children  are  still- 
born or  die  shortly  after  birth.    Even  among  those  that  survive, 


Fig.  188. 


Fig.  189. 


Hereditary    syphilitic    disease    of    the 
metacarpus    and    phalanges. 


Hereditary  syphilitic  disease  of  the 
joints.  In  this  case  the  interior  of 
the  right  knee-joint  was  lined  with 
hypertrophled  folds  of  synovial  mem- 
brane. A  complete  cure  followed  the 
administration  of  appropriate  reme 
dies. 


disease  of  the  bones  or  joints,  in  the  form  that  could  be  con- 
founded with  tuberculosis,  is  uncommon  as  compared  with  its 
other  manifestations.    Disease  of  the  bones  is  more  common  than 


NON-TUBEECULOUS  DISEASES  OF  THE  JOINTS.  273 

of  the  joints  because  as  contrasted  with  tuberculosis  it  usually 
involves  the  diaphyses.  It  is  in  further  contrast  of  the  forma- 
tive rather  than  of  the  destructive  type. 

Treatment. — Certain  writers  consider  hereditary  syphilis  to 
be  a  very  important  predisposing  cause  of  tuberculous  disease, 
and  believe  that  many  cases  classed  as  tuberculous  are  in  reality 
syphilitic,  even  if  no  history  or  confirmatory  signs  of  syphilis 
are  present.  As  evidence  on  this  point  the  observations  of 
Menard  may  be  cited.  He  found  in  16  of  700  tuberculous  cases 
under  treatment  positive  signs  of  hereditary  syphilis.  The 
possibility  of  the  syphilitic  taint,  remote  or  direct,  should  be 
borne  in  mind  and  in  all  doubtful  cases  appropriate  remedies 
should  be  employed.-^ 

In  general,  the  treatment  of  the  joint  affection  would  be  in- 
cluded in  the  treatment  of  the  disease  of  which  it  is  a  com- 
plication. If  the  joint  is  involved  in  a  destructive  process 
apparatus  to  ensure  rest  and  protection  is  indicated.  The  re- 
moval of  irritative  disease  in  the  neighborhood  of  a  joint  is 
sometimes  possible  in  older  subjects,  and  in  this  class  of  cases 
an  exploratory  incision  for  inspection  of  the  joint  is  sometimes 
advisable  (Fig.  189). 

ARTHRITIS. 

Gonorrhoeal  Arthritis Synonym.- — Gonorrhoeal   rheumatism. 

So-called  gonorrhoeal  rheumatism  is  an  inflammation  of  a 
joint  caused  by  the  presence  of  gonococci.  It  is  said  to  com- 
plicate from  2  to  5  per  cent,  of  all  the  cases  of  gonorrhoea, 
usually  appearing  in  the  later  stages  of  that  affection,  and  it  is 
more  common  among  those  who  are  in  a  debilitated  condition. 

Distribution.- — In  about  40  per  cent,  of  the  cases  it  is  mon- 
articular and  the  knee-joint  is  most  often  involved.  In  375 
cases  collected  by  Finger  the  distribution  was  as  follows  :^ 

Knee 136      Shoiilder    24 

Ankle 59      Hip 18 

Wrist   43      Jaw 14 

Finger-joints 35      Other  articulations 21 


Elbow 25 


375 


Bennecke^  has  tabulated  78  cases  in  56  patients,  of  whom 
18  were  males^  38  females.     The  distribution  was  as  follows: 

1  Menard,  Gaz.  des  Hop.,  48,  51,  1908.  ' 
^  Taylor,  Venereal  Diseases,  p.  263. 

^  Die  Gon.  Gelenkentziindung  nach  beob.,  der  Chir.  Univ.  Klin,  in  der  K. 
Charite  zu  Berlin.     Hirschwald,  Berlin,  1899. 

18 


274  OBTHOPEDIC  SUEGEEY. 

Knee 31      Shoulder   4 

Hip 8      Elbow 10 

Ankle 9      Wrist 6 

Other  joints  of  foot 6      Fingers 4 


In  46  cases  recorded  by  Markheim^  one  joint  was  involved  in 
13  cases,  two  joints  in  12,  three  joints  or  more  in  18.  The  order 
of  frequency  was  knee,  hip,  shoulder,  wrist,  and  elbow. 

Symptoms. — The  affection  is  usually  of  a  subacute  character. 
The  joint  becomes  swollen  and  there  is  discomfort,  and  particu- 
larly weakness  and  stiffness  on  use.  If  the  infection  is  more 
severe  there  may  be  local  heat,  pain,  and  infiltration  of  the 
tissues,  with  accompanying  muscular  spasm. 

In  all  the  forms  the  infiltration  of  the  subsynovial  tissues  of 
the  capsule  and  of  the  superficial  tissues  is  more  marked  than 
the  actual  effusion  within  the  joint  and  it  may  be  inferred  that 
in  many  instances  the  bone  is  itself  involved  although  not  to  the 
extent  to  be  classified  as  osteomyelitis.  The  more  serious  cases 
are  characterized  by  a  peculiar  (Edematous  swelling  of  the 
deeper  tissues,  the  skin  being  hot,  sensitive,  and  glazed.  There 
is  usually  intense  pain  on  motion  of  the  limb  or  on  jar.  After 
the  subsidence  of  the  acute  symptoms  the  thickening  persists, 
and  practical  anchylosis  may  result. 

Gonorrhoeal  arthritis  may  be  divided  into  three  classes  ac- 
cording to  its  symptoms  and  physical  characteristics :  the  serous, 
the  serofibrinous,  the  purulent. 

The  serous  form  is,  as  its  name  implies,  a  simple  effusion 
resembling  other  forms  of  subacute  synovitis,  although  it  is  of 
a  more  chronic  character. 

The  serofibrinous  variety  is  the  so-called  plastic  type  of  in- 
flammation. In  this  form  fibrin  is  deposited  upon  the  cartilage 
and  it  is  afterward  organized  by  the  growth  of  vessels  into  it 
from  the  synovial  membrane,  a  process  which  erodes  the  car- 
tilage upon  which  the  granulations  rest.  The  folds  of  the 
synovial  membrane  adhere  to  one  another,  the  capsule  is  thick- 
ened, and  ligaments  and  tendons  may  be  involved  in  the  ad- 
hesive inflammation.  These  changes  within  and  without  the 
joint  may  seriously  impair  its  function  after  the  cure  of  the 
active  disease. 

The  imrulent  form  is  uncommon ;  it  is  similar  in  its  charac- 
teristics to  suppurative  arthritis  from  other  causes.  It  is 
attended  by  great  local  heat,  pain,  and  swelling,  and  by  consti- 
tutional disturbance. 

'  Deutsche  Archiv  f .  klin.  Med.,  1902,  vol.  Ixxii.,  p.  186. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.  275 

111  orthopedic  clinics  gonorrhoeal  arthritis  is  usually  seen  in 
its  later  stages  when  the  acute  symptoms  have  subsided.  In 
these  cases  swelling  and  pain  persist  in  many  instances,  and  in 
the  more  severe  class  motion  is  limited  or  the  limb  may  be  fixed 
in  an  attitude  of  deformity.  An  obstinate,  monarticular  pain- 
ful swelling  of  a  joint  suggests  gonorrhoea,  and  its  presence  or 
absence  should  always  be  determined,  since  the  effective  treat- 
ment of  the  primary  cause  is  essential  to  the  cure  of  the  sec- 
ondary affection  of  the  joint.  The  same  statement  is  true  of 
painful,  persistent  affections  of  bursse  and  tendon  sheaths,  and 
of  obstinate  forms  of  weak  foot  in  which  sensitive  heels  and 
stiijened  toe  joints  are  present. 

Treatment.. — The  first  indication  is  the  cure  of  the  urethral 
disease.  Fuller,  of  l^ew  York,  has  reported  several  cases  in 
which  cure  of  persistent  disease  of  joints  and  tendon  sheaths 
followed  direct  treatment  of  gonorrhceal  disease  in  or  about  the 
seminal  vesicles.  The  injection  of  antigonococcic  serum  and 
gonococcic  bacterines  is  aiDparently  of  value. ^  The  local  treat- 
ment of  the  early  stage  of  this  form  of  arthritis  is  rest  and 
compression,  together  with  hot  or  cold  applications,  as  may 
seem  to  be  indicated.  Ichthyol  ointment  in  a  proportion  of 
about  40  per  cent,  appears  to  relieve  the  pain  and  to  stimulate 
the  absorption  of  the  effusion.  If  the  symptoms  are  acute 
and  if  there  is  constitutional  disturbance,  the  joint  should  be 
as|)irated,  and  if  the  examination  shows  the  effusion  to  be 
seropurulent,  it  should  be  incised,  irrigated  with  hot  salt  solu- 
tion and  closed.  In  the  chronic  form,  also,  when  the  capsule 
is  distended  by  the  serofibrinous  effusion,  incision  and  removal 
of  the  contents  is  indicated. 

In  the  latter  stages  of  disease  of  the  ordinary  subacute  type, 
the  treatment  is  directed  to  the  absorption  of  the  effused 
material  within  and  without  the  joint,  and  to  the  restoration  of 
functional  activity.  The  use  of  hot  air,  massage,  j)assive  con- 
gestion, the  hot  and  cold  douche,  static  electricity  and  the  like 
are  of  service  in  stimulating  the  circulation.  If  the  limb  has 
become  deformed,  and  if  it  is  fixed  by  adhesions  and  by  contrac- 
tions, the  deformity  may  be  corrected  by  forcible  manipulation 
under  ansesthesia.  And  it  may  be  stated  that  in  this  class  of 
cases  restoration  of  function  to  a  greater  or  less  degree  is  often 
accomplished  by  this  means.  • 

^  Swinburne,  Med.  Eecord,  Oct.  23,  1909. 

-The  injection  of  dead  bacteria  (ontogenous  inoculation)  in  the  treat- 
ment of  suppurative  complications  is  now  being  tested  at  the  Hospital  for 
Euptured  and  Crippled  with  apparent  success. 


276  OBTHOFEDIC  SUBGEBY. 

If,  however,  the  limb  is  fixed  in  the  proper  position  it  is  well 
to  postpone  forcible  measures  until  the  effect  of  the  massage  and 
gentle  passive  movements  have  been  observed. 

Functional  use  is  the  most  effective  restorative  treatment 
after  the  acute  symptoms  have  subsided.  This  is  made  possible 
by  the  employment  of  apparatus  which  limits  motion  to  the 
degree  the  joint  permits  without  causing  discomfort. 

Gonorrhoeal  Arthritis  in  Infancy. — This  complication  in  in- 
fancy is  usually  a  multiple  arthritis  of  a  pysemic  character.  In 
a  series  of  78  cases  of  gonorrhoeal  infection  treated  at  the  Babies 
HospitaP  there  were  ten  cases  of  arthritis,  six  died  directly 
from  the  disease,  two  died  later  from  exhaustion,  and  in  the 
two  remaining,  recovery  seemed  improbable. 

Puerperal  Arthritis. — This  is  so  similar  in  its  characteristics 
to  gonorrhoeal  arthritis  in  adults  that  a  detailed  description  is 
unnecessary.  It  may  be  stated,  however,  that  puerperal  arthritis 
is  usually  of  a  more  severe  type  than  the  preceding  affection. 

Arthritis  Complicating  Infectious  Diseases. — The  joints  may 
be  involved  in  the  course  of  any  infectious  disease.  A  mild 
form  of  arthritis,  often  involving  several  joints,  may  be  a  sequel 
of  infectious  disease,  notably  scarlatina.  Brade^  has  reported 
60  cases  of  joint  involvement  in  868  cases  of  scarlatina  treated 
in  St.  Jacob's  Hospital;  56  were  of  the  serous  type;  4  were  of 
the  suppurative  form,  causing  the  death  of  the  patients.  In  but 
.8  of  the  cases  was  the  arthritis  limited  to  a  single  joint. 

Arthritis  following  pneumonia  is  usually  of  a  more  severe 
type  than  the  preceding. 

Arthritis  complicating  typhoid  fever  is  often  of  a  severe  and 
destructive  type.  Keen^  has  tabulated  84  cases.  In  43  per 
cent,  of  these  the  hip-joint  was  affected  and  in  40  per  cent, 
spontaneous  dislocation  occurred.  In  a  case  treated  recently 
at  the  Hospital  for  Kuptured  and  Crippled  there  had  been  a 
destructive  arthritis  of  one  hip-joint,  spontaneous  displacement 
of  the  femur  on  the  other  side,  and  secondary  contractions  at 
the  knees  and  ankles,  so  that  the  patient  was  bedridden.  See 
Typhoid  Spine. 

Treatment. — The  treatment  in  all  forms  of  arthritis  compli- 
cating diseases  of  this  class  is  to  place  the  affected  joint  at  rest, 
to  apply  heat  or  cold  as  may  be  indicated  by  the  local  condition, 
and  to  prevent  the  secondary  distortions  that  lead  to  fixed  de- 

'  Kimball,  Med.  Eecorcl,  Nov.  14,  1903. 

2  Leipzig,  1903. 

^  Surgical  Complications  and  Sequels  to  Typhoid  Fever. 


NON-TUBEECULOUS  DISEASES  OF  THE  JOINTS.  277 

formities.  The  presence  of  pus  is,  of  course,  an  indication  for 
immediate  incision,  thus,  in  all  doubtful  cases  the  character  of 
the  effusion  should  be  ascertained  by  aspiration. 

Spontaneous  dislocation,  which  is  comparatively  common 
when  the  hip-joint  is  suddenly  distended  with  fluid,  is  not  likely 
to  occur  unless  the  limb  is  flexed  and  adducted.  This  attitude 
should  be  prevented  by  the  use  of  traction  or  support. 

The  after-treatment  has  been  indicated  already. 

Prognosis. — It  is  evident  that  the  immediate  reaction  to  bac- 
terial infection  and  the  final  results  will  vary  with  the  virulence 
of  the  infection,  the  natural  resistance  of  the  individual,  and 
of  the  part  involved.^  The  bacteria  reach  the  synovial  mem- 
brane through  the  capillaries  of  the  areolar  tissue,  beneath  the 
endothelium,  which  if  uninjured  serves  as  a  barrier  to  protect 
the  joint  cavity.  If  the  joint  is  not  actually  involved  the  restric- 
tion to  motion  will  depend  upon  thickening  of  the  tissues  of  the 
joint  and  upon  disuse  of  the  muscles.  In  such  cases  the  prog- 
nosis is  good.  If,  however,  the  interior  of  the  joint  is  invaded 
by  a  process  that  causes  adhesions,  and  partial  destruction  of 
the  cartilaginous  surfaces,  anchylosis  is  likely  to  follow. 

Acute  Arthritis  of  Infancy.- — A  form  of  acute  suppurative 
arthritis  primarily  within  the  joint  or  more  often  secondary  to 
disease  of  the  neighboring  epiphysis  is  not  uncommon  in 
infanc}^ 

Etiology. — The  disease  is  usually  caused  by  staphylococci, 
occasionally  by  other  forms  of  infection.  (See  Gonorrhoeal 
Arthritis.)  In  the  early  weeks  of  life  it  may  follow  infection 
at  the  umbilicus  or  other  surface  lesion.  It  may  be  secondary 
to  one  of  the  exanthemata  or  to  gonorrhoea,  but  in  many  in- 
stances the  origin  is  not  apparent. 

Falls  or  blows  upon  the  part  appear  to  be  predisposing  causes. 

Townsend^  tabulated  73  cases  of  acute  arthritis,  18  of  which 
were  personal  observations.  To  these  I  am  able  to  add  12 
others,  making  a  total  of  85  cases.  In  64  of  these  the  infection 
was  monarticular;  in  21  more  than  one  joint  was  involved.  The 
distribution  was  as  follows : 

Hip-joint    45  ^  53  per  cent. 

Knee-joint    32  :=  37  per  cent. 

Other  joints    8  =  10  per  cent. 

Sex.. — The  sex  was  specified  in  61  cases:  males,  38;  females, 

23.     It  is  of  interest  to  note  that  in  all  reported  cases  the  males 

^  Poynton  and  Paine,  British  Medical  Journal,  November  1,  1902. 
-  American  Journal  of  the  Medical  Sciences,  January,  1890. 


278  OETHOPEDIC  SUBGEBY. 

outnumber  the  females.  In  285  cases,  including  the  above  and 
others  reported  by  Gonser,  Demme,  Llicke,  Billroth,  Schede^ 
and  Mliller,  the  proportion  was  nearly  3  to  1.^ 

Symptoms., — If  the  infection  is  severe  there  is  immediate  local 
heat,  redness,  swelling  and  cedema,  great  pain,  and  correspond- 
ing constitutional  disturbance.  But  in  many  instances  the  local 
and  general  symptoms  are  less  marked,  the  child  is  fretful,  and 
the  evident  discomfort  caused  by  motion  at  the  affected  joint  is 
mistaken  for  result  of  injury  or  rheumatism.  In  this  class  of 
cases  the  patient  is  not,  as  a  rule,  seen  until  several  weeks  after 
the  onset  of  the  affection.  The  joint  is  then  somewhat  infil- 
trated and  enlarged,  motion  is  painful  and  restricted,  and  the 
general  appearances  are  very  similar  to  tuberculous  disease. 
There  are  also,  without  doubt,  even  milder  forms  of  synovial 
infection  from  which  recovery  is  rapid  and  practically  complete. 
These  cases  are  usually  classed  as  monarticular  rheumatism. 
Similar  symptoms  may  be  induced  directly  by  injury;  motion 
causes  pain;  the  limb  is  flexed  and  persistent  deformity  may 
result  unless  protection  is  assured. 

Treatment. — The  treatment  of  suppurative  arthritis  is  free 
incision  and  efficient  drainage.  In  all  cases  the  joint  must  be 
fixed,  preferably  by  a  light  wire  splint,  during  the  active  stage 
of  the  disease.  An  apparatus  is  usually  required  to  prevent 
deformity  or  to  support  the  weak  limb  when  the  patient  begins 
to  walk. 

Prognosis.- — If  the  disease  is  confined  to  the  joint  complete 
recovery  may  follow  evacuation  of  the  pus,  but,  as  a  rule,  the 
neighboring  epiphyseal  junction  is  diseased,  suppuration  is 
prolonged,  and  a  part  of  the  epiphysis  is  destroyed  before  the 
disease  comes  to  an  end ;  thus,  subluxation  or  displacement  with 
subsequent  deformity  and  loss  of  growth  are  the  usual  results 
of  this  form  of  disease.  At  the  hip-joint,  for  example,  the 
laxity  of  the  ligaments  and  the  upward  displacement  of  the 
femur  that  follow  destruction  of  the  head  of  the  bone  cause 
symptoms  that  in  later  life  are  often  mistaken  for  those  of  con- 
genital dislocation. 

In  some  of  the  cases  there  is,  in  addition  to  the  arthritis,  an 
osteomyelitis  of  the  shafts  of  one  or  more  of  the  bones.  These 
cases  are  usually  fatal,  or,  if  the  patient  survives,  there  is 
usually  necrosis  of  the  affected  bones  and  consequently  extreme 
deformity. 

•  '  Gonser,  Jahrbneli  f.  Kiiulerheilk..  July,  1902. 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS.  279 

In  the  cases  reported  by  Townsend  the  death-rate  was,  in  the 
monarticular  form,  18  per  cent. ;  in  the  multiple  form,  Y3 
per  cent. 

In  a  total  of  122  cases  of  all  varieties  tabulated  bj  Hoffmann, 
the  death-rate  was  46  per  cent.    In  87  the  affection  was  confined 

Fig.  190. 


Deformities  resulting  from  infections   osteomyelitis. 

to  one  joint;  in  the  remainder  from  two  to  five  joints  were 
involved.-^ 

Acute  Tuberculous  Arthritis. — In  early  infancy  forms  of 
acute  tuberculous  disease,  especially  at  the  knee-joint,  may  simu- 
late closely  infectious  arthritis.     The  joint  may  become  swollen, 

^  Medical  Bulletin,  Washington  University,  September,  1902. 


280 


OBTHOPEDIC  SUBGEBY. 


hot,  and  sensitive  to  pressure,  and  the  onset  may  be  sudden  and 
accompanied  by  constitutional  disturbance.  Such  cases  are 
more  often  observed  in  the  children  of  mothers  suffering  from 
advanced  disease  of  the  lungs. 


ACUTE  OSTEOMYELITIS. 


Infectious  osteomyelitis  is  most  common  in  adolescence  and 
the  extremities  of  the  bones  in  the  neighborhood  of  the  epiphy- 


FiG.  191. 


Tuberculous  osteomyelitis  localized  in  the  lower  extremities  of  the  radius 
and  ulna,  demonstrated  by  the  a;-ray  and  removed  before  the  wrist-joint  was 
involved. 

seal  cartilages  are  most  often  involved.  Trendel,  from  the 
histories  of  1058  cases  in  Bruns'^  clinic,  states  that  it  is  most 
common  in  the  period  from  the  thirteenth  to  the  seventeenth 
year.  In  one-half  the  cases  the  femur  was  involved;  in  one- 
third  the  tibia.  Injury  has  apparently  an  important  determin- 
ing influence  on  the  localization  of  the  disease. 

The  symptoms  are  local  sensitiveness  of  the  bone,  pain,  and 
constitutional  disturbance.      The  neighboring  joint  is  usually 
^  Beit.  zur.  kliu.  Chir.,  Bel.  xli.,  p.  3. 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS.  281 

distended  by  a  sympathetic  synovitis,  and  the  overlying  tissues 
are  usually  infiltrated.  The  treatment  consists  in  immediate 
opening  of  the  bone  at  the  suspicious  point,  in  order  to  relieve 
the  tension  and  to  establish  drainage.  In  certain  instances  the 
joint  itself  may  be  directly  involved  in  the  disease.  This  may 
be  inferred  if  the  symptoms  do  not  subside  after  the  bone  has 

Fig.  192. 


Loss    of   growth    following   osteomyelitis    of   the   tibia,    necessitating    removal    of 

part  of  the   shaft. 

been  opened.  In  doubtful  cases  the  joint  should  be  aspirated 
for  the  purpose  of  bacteriological  examination,  but  even  if  patho- 
genic bacteria  are  present  the  treatment  by  incision  or  otherwise 
must  be  decided  on  the  clinical  symptoms. 

For  the  investigations  of  FraenkeP  show  that  specific  micro- 
organisms are  present  in  the  red  marrow  of  the  vertebra,  in  the 
ribs  and  elsewhere  in  every  form  of  infectious  disease,  and  that 
they  may  be  found  here  even  when  they  are  absent  in  the  blood. 
In  the  blood,  according  to  Bertelsmann,^  they  may  be  found  in 
about  one-third  of  all  cases  of  surgical  infection  and  far  more 

^  Mit  a.  d.  grenzgebieten  d.  Med.  u.  Chir.,  Bd.  xii. 
=  Deutsch.  Zeit.  f.  Chir.,  Bd.  Ixxii.,  p.  209. 


282  OBTHOPEDIC  SUBGEEY. 

often  when  bones  or  joints  are  involved.  In  a  series  of  48  posi- 
tive results  streptococci  were  found  in  68  per  cent.,  staphylococci 
in  30  per  cent. 

The  prognosis  in  neglected  cases  is  bad :  for  example,  in  54 
cases  of  acute  osteomyelitis  of  the  upper  extremity  of  the  femur, 
in  all  but  seven  of  which  the  joint  was  involved,  the  death-rate 
was  60  per  cent.^ 

Localized  osteomyelitis  in  the  neighborhood  of  a  joint  may 
simulate  tuberculous  disease  of  the  joint.  The  onset  of  the 
affection  is,  however,  more  abrupt,  the  surrounding  tissues  are 
infiltrated,  and  the  symptoms  are  usually  more  acute  than  in  the 
latter  affection.  In  this  class  of  cases  of  the  subacute  type  the 
lesions  are  often  multiple,  fresh  foci  appearing  at  intervals  for 
an  indefinite  time.  The  treatment  of  choice  when  the  affection 
is  localized  is  the  operative  removal  of  the  diseased  area,  which 
is  indicated  by  local  sensitiveness,  and  which  in  many  instances 
may  be  demonstrated  by  the  X-ray.  One  should  be  as  sparing 
of  the  bone  as  possible  because  of  the  danger  of  retardation  or 
irregularity  of  growth  that  almost  always  follows  the  loss  of 
even  a  moderate  amount  of  growing  tissue.  The  iodoform  fill- 
ing of  Mosetig-Moorhof  may  be  used  with  advantage  in  this 
class  of  cases. 

ARTHRITIS  DEFORMANS.     OSTEOARTHRITIS  AND  RHEUMA- 
TOID ARTHRITIS.     RHEUMATIC  GOUT.    DEGENERATIVE 
AND    PROLIFERATIVE    ARTHRITIS. 

Under  these  titles  are  included  a  group  of  chronic  diseases  of 
the  joints  whose  etiology  is  obscure.  At  the  present  time  as 
these  diseases  are  often  classed  as  varying  manifestations  of  one 
pathological  process,  the  titles  are  usually  considered  as  syn- 
onymous. 

Clinically,  however,  the  characteristic  types  differ  markedly 
from  one  another.  In  one  form  bone  destruction  is  combined 
with  bone  formation,  and  the  final  result  is  an  irregular  solid 
enlargement  of  the  joint,  usually  combined  with  distortion  of 
the  limb. 

The  term  hypertrophic  arthritis  may  be  applied  to  this  type. 

The  second  form  resembles  chronic  rheumatism  in  its  course 
and  distribution.  '  The  joints  are  enlarged  but  the  disease  is 
essentially  of  the  soft  parts,  the  articulating  surfaces  are  only 

'  Gyot,  Eev.  des  Chir.,  xxiv.,  Nos.  2  and  4. 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS. 


283 


secondarily  and  superficially  involved.  There  is  no  new  forma- 
tion of  bone  or  cartilage  but  eventually  general  atrophy  of  the 
limb. 

The  final  result  is  deformity  and  limited  motion  or  anchylosis 
without  bony  enlargement  of  the  joint.  This  form  may  be 
classed  from  the  clinical  standpoint  as  atrophic  to  distinguish 

Fig.  193. 


Hypertrophic  arthritis.  The  hypertrophy  of  the  extremities  of  the  bones  of 
the  terminal  phalanges  (Ileberden's  nodes)  is  accompanied  by  erosion  of  the  car- 
tilage. The  second  interphalangeal  joint  of  the  second  finger  shows  hypertrophy; 
combined  with  destruction  and  lateral  displacement.      (See  Fig.   194.) 


it  from  the  former  or  hypertrophic  form  of  arthritis  deformans 
if  this  tenn  is  used  to  include  both  varieties. 

Hypertrophic  Arthritis. — Pathology. — The  characteristic  type 
is  that  seen  in  elderly  subjects,  sometimes  limited  to  a  single 
joint — Malum  Coxse  Senile,  for  example.     The  primary  effects 


284 


ORTHOPEDIC  SUSGEBY. 


of  the  disease  are  most  noticeable  in  the  cartilage,  ^vhich  becomes 
fibrillated  and  finally  is  worn  away  in  the  parts  subjected  to 
greatest  pressure,  while  it  is  thickened  and  heaped  up  into 
irregular  layers  at  the  periphery,  as  if  under  the  influence  of 
pressure  it  had  been  squeezed  out  from  the  interior  of  the  joint 

Fig.  194. 


Atrophic   arthritis.     Slight   superficial   erosions    of  the  bones   are   to   be   seen   at 
several   of  the  joints.   Contrast   with  Fig.   103. 

(Fig,  195).  When  the  cartilage  disappears,  the  bone,  deprived 
of  its  natural  protection,  is  worn  away,  and  under  the  influence 
of  pressure  and  friction  it  becomes  increased  in  density  and 
hardness,  "  ebumated."  Meanwhile  the  irregular  projections 
of  cartilage  at  the  periphery  become  in  part  ossified,  and  this, 
together  with   a  formative  periostitis   of  the   adjoining  bone. 


NON-TUBEECULOUS  DISEASES  OF  THE  JOINTS.  285 

causes  the  irregular  bony  enlargement  combined  with  destruc- 
tion of  the  bearing  surfaces  of  the  bones  characteristic  of  the 
disease.  The  contour  of  the  bones  and  their  mutual  relation 
to  one  another  in  the  joint  are  changed.  The  synovial  mem- 
brane becomes  hypertrophied  and  its  villi,  some  of  v^hich  may 
contain  cartilaginous  nodules,  project  into  the  joint  in  shaggy 
fringes.  These  may  be  detached  from  time  to  time  and  may 
form  loose  bodies  within  the  capsule.  The  synovial  fluid  may 
be  greatly  increased  in  quantity  distending  the  capsule,  or, 
communicating  with  bursse,  it  may  form  cysts,  as  is  sometimes 
observed  at  the  knee-joint.  But  more  commonly  the  fluid  is 
decreased  in  amount.  The  ligaments  are  weakened  and  the  ten- 
dons about  the  joint  become  adherent  to  their  sheaths  and  to  the 
neighboring  tissues.  The  muscles  atrophy  and  become  structur- 
ally shortened  or  otherwise  changed  in  accommodation  to  the 
deformity.  Motion  is  limited  by  the  changes  in  and  about  the 
joint  but  anchylosis  is  unusual. 

Although  the  most  noticeable  of  the  early  changes  appear 
in  the  cartilage  it  is  probable  that  the  nutrition  of  the  under- 
lying bone  is  lowered  in  the  beginning  and  that  the  joint  is 
involved  as  a  whole  rather  than  that  the  disease  is  primarily  of 
the  cartilage  as  formerly  taught. 

Etiology. — Little  that  is  positive  is  known  of  the  etiology. 
Several  factors  are  sufiiciently  evident.  These  are  age,  injury 
or  overstrain,  overweight  and  improper  functional  use.  The 
wearing  out  of  the  joint  is  suggested  by  the  appearances,  and, 
as  is  well  known,  similar  changes  in  slight  degree  are  not  un- 
commonly found  in  the  joints  of  laborers  of  middle  age.  So, 
alsOj  similar  changes  may  follow  injury,  particularly  fracture 
at  the  hip- joint.  In  elderly  and  overweighted  subjects  the 
symptoms  may  be  induced  by  slight  disturbance  of  the  normal 
relation  of  the  bones ;  in  the  knee,  for  example,  as  a  sequel  of 
weak  foot.  Lessened  local  and  general  resistance  are  also  pre- 
disposing causes.  In  locomotor  ataxia,  a  disease  accompanied 
by  loss  of  sensation  and  by  diminished  control  of  movement,  the 
nutrition  of  the  joint  is  lowered  and  its  natural  safeguards 
against  injury  and  overwork  are  removed.  Joint  disease  (Char- 
cot's disease)  in  such  instances  is  undoubtedly  an  indirect  effect 
of  disease  of  the  nervous  apparatus,  but  it  by  no  means  follows 
that  such  or  any  disease  of  the  nervous  system  is  necessary  to 
explain  the  lesions  of  the  ordinary  form.  It  may  be  mentioned 
in  this  connection  that  disease  of  similar  nature  is  very  common 


286 


OETHOPEDIC  SUBGEBT. 


among  domestic  animals  in  old  age.  It  has  been  suggested,  and 
it  is  probably  true,  that  defective  assimilation  (metabolism) 
may  be  a  causative  factor  in  both  man  and  animals. 

Symptoms. — In  its  typical  form  hypertrophic  arthritis  is  an 
affection  of  middle  life  and  of  old  age.     It  may  be  confined  to  a 


Fig.  195. 


1    Jl 

1^ 

Hypertrophic    arthritis,    from    the    Museum    of    the    College    of    Physicians    and 
Surgeons,   New  York. 


single  joint,  and  in  these  cases  one  of  the  larger  joints  of  the 
lower  extremity  is  more  often  affected,  particularly  the  hip  or 
knee.  As  a  rule,  however,  several  joints  are  involved  to  a  greater 
or  less  degree.  Its  onset  is  usually  insidious,  and  the  progress  is 
slow,  accompanied  by  remission  of  the  symptoms. 

These  symptoms  are  usually  pain,  discomfort  in  changing 
from  one  position  to  another,  "  creaking "  sensations  in  the 
affected  joints,  gradually  increasing  local  enlargement  and  sen- 
sitiveness, limitation  of  motion,  and  distortion  of  the  limb. 
Typical  examples  are  found  in  the  hip-joint  (malum  coxse  senile) 
and  knee,  and  these  are  described  elsewhere. 

i\.lthough  the  disease  may  be  confined  to  one  or  more  of  the 


NON-TUBEECULOUS  DISEASES  OF  THE  JOINTS.  287 

larger  articulations,  it  is  often  accompanied  by  enlargement  of 
the  joints  of  the  fingers.  It  should  be  stated,  also,  that  there  is 
a  form  of  hypertrophic  arthritis  of  comparatively  slight  im- 
portance in  which  the  disease  is  confined  to  the  joints  of  the 
fingers.  The  bases  of  one  or  more  of  the  distal  phalanges  be- 
come enlarged  (Heberden's  nodosities),  and  the  fingers  become 
somewhat  stiff  and  painful,  the  pathology  being  very  simi- 
lar to  that  already  described.  Gradually  other  phalangeal 
joints  become  involved  until  the  fingers  become  deformed  and 
function  is  somewhat  interfered  with.  The  disease  is  slowly 
progressive,  pain  lessening  as  the  enlargement  and  stiffness 
become  more  apparent.  When  the  disease  begins  in  this  man- 
ner the  larger  joints  are  not  often  implicated.  It  is  interesting 
to  note,  however,  that  this  form  of  disease  is  far  more  common 
in  women  than  in  men,  and  it  may  be  accompanied  by  disease 
of  the  larger  joints  of  the  nature  of  (atrophic)  arthritis 
(Fig.  193). 

Treatment.. — In  general,  this  should  be  directed  to  the  im- 
provement, if  possible,  of  the  condition  of  the  patient.  The 
daily  routine  should  conform  to  what  the  personal  experience  of 
the  patient  shows  to  be  that  best  adapted  to  the  disability.  The 
local  nutrition  may  be  maintained  by  massage,  electricity,  and 
the  like.  Deformity  may  be  prevented  and  pain  may  be  relieved 
by  regulating  the  strain  to  which  the  weak  part  is  subjected,  if 
practicable  by  the  use  of  apparatus.  In  certain  instances  opera- 
tive removal  of  villous  proliferations  of  the  synovial  membrane 
or  of  solid  projections  that  interfere  with  movement  may  be  of 
service.  (See  Spondylitis  Deformans  and  Osteoarthritis  of  the 
Hip  and  Knee.) 

Atrophic  Arthritis. — Atrophic  arthritis  differs  from  the  pre- 
ceding type  in  that  it  is  rather  an  affection  of  childhood  and  of 
early  adult  life  than  of  old  age.  It  is  more  common  among 
females  than  males.  It  is  more  acute  in  its  onset,  more  rapidly 
progressive,  and  more  general  in  its  distribution  than  the 
typical  hypertrophic  form. 

In  hypertrophic  arthritis  the  cartilage  is  worn  away  at  the 
centre  of  the  joint,  heaped  up  at  the  periphery  and  the  under- 
lying bone  is  involved.  In  typical  atrophic  arthritis  the  affec- 
tion is  primarily  of  the  fibrous  coverings  and  of  the  membranes 
of  the  joint,  and  the  cartilage  is  destroyed  in  the  later  stages  by 
a  pannus-like  growth  from  the  periphery.  There  is  secondary 
erosion  of  the  cartilage  and  of  the  underlying  bone  unaccom- 


288 


ORTHOPEDIC  SUBGEBY. 


panied  by  the  hypertrophy  characteristic  of  the  preceding  dis- 
ease. A  spindle-shaped  enlargement  of  the  finger-joints  is  char- 
acteristic, but  the  X-ray  picture  will  not  show  irregular  bone  for- 
mation but  a  normal  contour  or  at  most  superficial  erosions  of  the 
bones  entering  into  the  formation  of  the  joint.    The  second  inter- 


FiG.  196. 


Atrophic    arthritis    in    a    child,    showing    the    characteristic    deformity, 
every  joint  in  the  body  is   involved. 


Nearly 


phalangeal  joints  are  usually  involved  primarily.  There  is  usually 
flexion  contraction,  and  in  many  instances  general  deviation  of 
the  fingers  toward  the  ulnar  side.  In  younger  subjects,  particu- 
larly in  the  class  of  cases  in  which  the  onset  of  the  disease  is 
acute,  and  in  which  there  is  considerable  effusion,  there  may  be 
subluxation  or  actual  luxation  of  the  phalanges,  more  often  at 
the  metacarpal  articulations,  combined  with  more  or  less  absorp- 
tion of  the  extremities  of  the  bones.  In  such  instances  motion 
is  preserved  in  the  affected  joints. 

In  typical  cases  the  final  result  in  any  joint  is  either  anchy- 
losis or  limited  motion  accompanied  by  flexion  deformity. 
There  is,  of  course,  general  atrophy  of  the  muscles  and  of  the 
bones  corresponding  in  degree  to  the  functional  disability  that 
is  present. 

The  onset  of  atrophic  arthritis  may  be  acute,  resembling 
rheumatism,  many  joints  being  involved  simultaneously.  It  is 
usually  subacute  and  even  limited  primarily  to  a  single  joint, 
slowly  extending  its  area. 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS. 


289 


Tlie  larger  joints  may  be  involved  before  those  of  the  hands, 
or  vice  versa.  In  childhood  the  disease  often  begins  in  one  of 
the  larger   joints,   causing   stiffness,    deformity,    and   pain   on 

Fig.  197. 


Still's  form  of  polyarthritis,  sliowing  the  general  atrophy,  the  enlarged  joints, 
and  the  prominence  of  the  abdomen,  due  to  amyloid  degeneration  of  the  liver 
and  spleen. 

motion.  There  is  nsnally  some  local  heat  and  infiltration,  in- 
creasing and  diminishing  according  to  the  character  of  the 
disease  and  to  the  strain  or  injury  to  v^hich  the  joint  may  be 

Fig.  198. 


The  hands  in  the  case  shown  in  the  preceding  figure. 


subjected.     In  cases  of  this  character  the  affection  is  usually 
mistaken  for  tuberculous  disease  until  the  involvement  of  other 
19 


290  OETHOPEDIC  SUBGEBY. 

joints  indicates  the  true  character  of  the  affection.  As  a  rule, 
the  affection  is  progressive  in  character,  both  locally  and  gen- 
erally. The  range  of  motion  in  the  affected  joint  becomes  more 
and  more  restricted,  the  limb  becomes  flexed,  and,  finally,  there 
is  practical  anchylosis,  usually  due  to  adhesions  and  contractions 
within  and  without  the  joint.  In  those  cases  in  which  the 
cartilage  is  in  part  destroyed  by  the  growth  of  granulation 
tissue  from  the  periphery  there  may  be  actual  bony  union.  In 
many  instances  the  spine  becomes  rigid,  including  the  occi- 
pitoaxoid  articulations,  and  practically  every  joint  of  the  body 
may  be  finally  involved,  so  that  the  patient  is  bedridden  and 
helpless. 

The  disease  is  more  serious  and  more  rapidly  progressive  in 
the  young  than  in  older  subjects.  There  are  periods  of  remis- 
sion and  of  exacerbation.  In  some  instances  the  disease  appears 
to  come  definitely  to  an  end,  leaving  the  stiffened  joints,  and 
occasionally  complete  recovery  takes  place,  but  this  is  unusual. 

A  peculiar  form  of  the  affection,  first  described  by  Still, ^ 
occurs  in  childhood.  This  begins  usually  in  one  or  more  of  the 
larger  joints.  As  a  rule,  it  progresses  rapidly,  and  it  is  accom- 
panied by  enlargement  of  the  lymphatic  glands,  particularly 
those  of  the  inguinal  region  and  axilla,  and  of  the  liver  and 
spleen.  There  is,  as  a  rule,  moderate  effusion  into  the  joints 
and  thickening  of  the  overlying  tissues.  As  the  muscular 
atrophy  is  extreme,  the  joints  appear  by  contrast  very  much 
enlarged.  The  final  outcome  of  the  disease  if  the  patient  sur- 
vives is  anchylosis  and  deformity,  as  in  the  ordinary  form. 
Occasionally  complete  recovery  occurs. 

Etiology.' — Of  the  etiology  of  atrophic  arthritis  little  is  known. 
Certain  aspects  of  the  disease  resemble  closely  those  caused  by 
infection  from  without.  This  is  particularly  noticeable  in  those 
cases  in  which  the  disease  begins  in  one  or  more  of  the  larger 
joints.  On  the  other  hand,  infectious  joint  disease  of  the  ordi- 
nary form  is  not  slowly  progressive,  as  is  typical  atrophic  arthri- 
tis. It  is  probable,  however,  that  certain  forms  of  infectious 
arthritis  of  a  mild  character  are  included  in  what  is  now  known 
as  atrophic  arthritis.  Autoinfection,  due  to  defective  assimila- 
tion, is  probably  a  predisposing  and  exciting  cause,  as  it  is  well 
known  that  this  aggravates  the  symptoms  of  the  disease  when 
it  is  once  established. 

Contributing  causes  are  apparently  an  inherited  lack  of  vital 
^  Medico-CMrurg.  Transactions,  1897, 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS. 


291 


resistance  or  acquired,  it  may  be,  by  overwork  or  strain,  mental 
or  physical. 

Treatment.. — In  general,  this  must  be  directed  to  improving 
the  condition  of  the  patient  by  the  regulation  of  the  diet,  which 
must  be  nourishing  and  easily  assimilated.  Hoke  has  called 
especial  attention  to  intestinal  putrefaction  as  a  factor  in  the 
disease.  Thorough  catharsis  having  been  established  a  diet 
limited  to  sour  milk  (Kifolac)  has  in  his  practice  proved  effec- 
tive in  checking  the  progress  of  the  disease.  Exposure  to  cold 
and  wet,  and  overexertion  must  be  avoided.  The  use  of  static 
electricity,  the  hot-air  and  the  electric-light  baths,  as  general  and 

Fig.  199. 


Atrophic  arthritis  iu  u  child  all'ecling  the  joints  and  the  spine,  progressive  in 
character,  accompanied  by  enlargement  of  the  lymphatic  glands.  The  attitude 
of  the  head  is  characteristic  of  suboccipital  disease.  The  case  is  one  of  the 
Still   type. 


local  stimulants,  are  of  service.  Ichthyol  ointment,  the  cautery, 
and  the  like  may  be  employed  locally.  Large  doses  of  potassium 
iodid  are  sometimes  of  service  and  recently  the  extract  of  thymus 
gland  from  15  to  60  grams  daily  has  been  recommended.-^ 
If  the  joints  are  sensitive  motion  should  be  restricted  to  the 
painless  area  by  apparatus.  Passive  motion  or  massage  that 
increases  the  pain  or  discomfort  is  harmful,  but  motion  should 
1  Nathan,  Am.  J.  Med.  Sci.,  June,  1909. 


292  OETHOPEDIC  SUBGEBY. 

be  encouraged  when  the  disease  is  quiescent.  Contraction  de- 
formity may  be  overcome  bv  forcible  manipulation,  and,  if  nec- 
essary, by  tenotomy  when  the  disease  is  quiescent.  And  it  has 
even  been  suggested  that  forcible  manipulation  under  ether  may 
have  a  general  as  well  as  local  remedial  effect.  Excision  of  an 
anchylosed  joint,  as  of  the  lower  jaw  or  elbow,  may  re-establish 
painless  motion.^ 

The  treatment  of  infectious  arthritis  has  been  discussed.  It 
may  be  that  a  primary  infection  of  a  single  joint  or  of  other 
tissues  or  organs  may  be  the  starting  point  of  multiple  arthritis. 
In  such  cases  operation  with  the  aim  of  removing  the  focus  of 
infection  may  be  considered. 

It  may  be  noted  as  of  interest  that  what  appears  to  be  typical 
atrophic  arthritis  in  childhood  may  be  induced  apparently  by 
infectious  disease,  such  as  diphtheria  for  example,  and  that  im- 
provement, or  even  disappearance,  of  the  local  symptoms  may 
follow  intercurrent  attacks  of  scarlatina  or  measles.  It  is  possi- 
ble, therefore,  that  serum-therapy  may  be  employed  in  the 
future. 

Although,  as  has  been  indicated,  typical  cases  of  atrophic 
and  hypertrophic  arthritis  differ  so  essentially  as  to  be  classed 
as  distinct  diseases,  yet  there  are  types  that  it  is  difficult  to 
classify  as  the  one  or  the  other,  and  in  certain  instances  the 
two  forms  may  be  combined  in  one  individual. 
.  Xichols  and  Richardson-  have  carefully  investigated  the  sub- 
ject from  the  pathological  standpoint.  They  conclude  that  there 
are  two  pathological  types  of  this  class  of  joint  disease. 

1.  The  degenerative,  or  what  has  been  described  as  the  hyper- 
trophic form,  which  tends  to  destroy  the  joint  cartilage  and  to 
produce  deformity  without  anchylosis  (Figs.  199-200). 

2.  The  proliferative  or  atrophic  fonn  which  tends  to  destroy 
the  joint  cartilage  and  leads  to  anchylosis  (Figs.  201—202). 

Gout. — Gout  is  comparatively  of  slight  importance  from  the 
orthoiDedic  standpoint.  It  affects  more  particularly  those  of 
middle  life  and  it  is  characterized  by  acute  inflammatory  at- 
tacks followed  by  deposits  of  urate  of  sodium  on  or  about  the 
articular  surfaces  of  the  affected  joints.  After  repeated  attacks 
the  cartilage  and  the  bone  may  be  in  part  destroyed,  and  the 
joint  may  be  enlarged  by  deposits  in  the  periarticular  tissues  and 
by  the  inflammatory  thickening  of  the  neighboring  joints.     The 

^Whitman,  Medical  Eecorcl,  April  IS,  1903. 
^  Arthritis    Deformans,    Boston,    1910. 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS. 


293 


joints  most  often  involved  are  that  of  the  great  toe,  the  ankle, 
knee,  and  the  joints  of  the  fingers.  If  the  feet  are  weakened  or 
distorted  as  the  effect  of  gout,  a  proper  support  to  distribute  the 
weight  more  generally  on  the  sole  is  often  of  service.      The 


Fig.  200. 


Degenerative  arthritis  ;  moderate  degree.  Ptiotomicrograpli  of  section  througii  a 
plialangeal  joint  and  adjacent  plialanges  sliows  that  the  line  of  the  joint  cavity  is 
very  irregular.  Areas  of  hyperplasia  of  the  cartilage  (1),  with,  in  other  places, 
erosion  of  the  cartilage  down  to  eburnated  bone  of  the  opposing  phalanx  (2). 
In  other  cases  the  cartilage  shows  fibrillation  (3).  There  is  moderate  thick- 
ening of  the   capsule.      (Nichols   and   Richardson.) 

Fig.  201. 


Degenerative  arthritis  ;  moderate  degree.  Photomicrograph  of  the  phalangeal 
joint  and  adjacent  phalanges.  The  line  of  the  joint  cavity  is  very  irregular  (1)  ; 
the  cartilage  has  been  almost  entirely  destroyed  and  shows  only  at  the  margins 
of  the  joint  (2,  2)  ;  the  articular  surface  of  the  phalanges  where  the  cartilage 
has  been  destroyed  is  eburnated  (3,  3).  There  has  been  a  new  growth  of  bone 
at  the  periphery  of  the  joint  (beginning  Heberden's  node)  (4).  (Nichols  and 
Richardson.) 


operative  removal  of  unsightly  deposits  about  joints  may  be 
considered  also.  The  general  treatment  of  the  patient  is  of 
course  of  the  first  importance. 

Rheumatism. — Certain  forms  of  rheumatism,  so  called,  are 
of  interest  from  the  orthopedic  standpoint,  notably  those  forms 


294 


OBTHOPEDIC  SUBGEBY. 


that  affect  the  fibrous  tissues  and  that  lead  to  permanent  changes 
in  the  joints — "  plastic  rheumatism."  Undoubtedly  monarticu- 
lar arthritis  is  usually  due  to  direct  infection  from  without,  as 


Fig.  202. 


Proliferative  artliritis :  extreme  type.  Photomicrograph  of  section  through 
phalangeal  joint.  The  trabeculae  of  the  phalanges  are  less  numerous  than 
normal ;  the  capsule  is  slightly  thickened  :  the  joint  cavity  is  much  reduced  in 
size  by  extension  inward  of  dense,  fibrous  tissue  from  the  synovial  membrane 
-at  the  point  indicated  by  the  circle :  this  fibrous  pannus  is  adherent  to  both 
Joint  cartilages,  producing  adhesion  and  loss  of  motion  without  destruction  of 
the    underlying   cartilage.       (Nichols    and    Richardson.) 

Fig.  203. 


Proliferative  arthritis :  extreme  type.  Vertical  section  through  phalangeal 
joint.  Shows  the  distal  phalanx  (1)  ;  dislocated  forward  and  downward  into  the 
palm  of  the  hand;  the  joint  cavity  (2)  is  practically  obliterated  and  replaced  by 
loose,  dense,  fibrous  adhesions.  The  joint  cartilage  has  entirely  disappeared  ;  the 
trabecule  of  the  phalanges  are  less  numerous  and  smaller  than  in  normal  bone. 
(Nichols  and  Richardson.) 


NON-TUBEECULOUS  DISEASES  OF  THE  JOINTS.  295 

are  certain  forms  of  polyarthritis.  Xotably  those  that  follow 
infectious  diseases.  A  form  of  subacute  arthritis  is  sometimes 
observed  as  a  complication  of  tuberculous  disease,  "  tuberculous 
rheumatism."  There  are  other  forms,  for  example,  arthritis 
deformans,  gout  and  the  like  in  which  defective  assimilation 
and  lessened  resistance  are  the  important  factors. 

H.ffiMOPHILIA. 

Haemophilia  is  apparently  a  congenital  weakness  of  the  blood- 
vessels which  is  transmitted  through  females  to  males.  In  one 
family  under  observation  since  1827,  through  four  generations 
(207  members),  there  were  37  '"bleeders,"  all  males;  33  per 
cent,  of  the  male  descendants.  Eighteen  died  from  the  effects 
of  hemorrhage,  nearly  all  in  childhood.-'  In  a  family  known  to 
the  writer  all  the  males,  three  in  number,  died  of  hemorrhage, 
two  having  lived  to  adult  age. 

Hemorrhage  into  a  joint  in  this  class  is  not  uncommon,  the 
knee-joint  being  most  often  involved.  As  a  rule,  it  is  the  result 
of  injury,  and  if  the  peculiarity  of  the  patient  is  known  the 
nature  of  the  effusion — hemorrhagic — is  hardly  doubtful,  par- 
ticularly as  there  are  in  many  instances  discolorations  of  the  skin, 
either  over  the  joint  or  elsewhere.  In  some  instances  there  is 
no  history  of  traumatism,  and  the  swelling  may  be  accompanied 
by  fever.  This  is  probably  the  eft'ect  of  the  hemorrhage  rather 
than  its  cause. 

The  peculiar  interest  in  the  affection,  aside  from  the  im- 
portance of  a  proper  diagnosis,  lies  in  the  fact  that  the  further 
organization  of  the  effused  blood  may  cause  symptoms  and 
changes  about  the  joint  that  may  be  mistaken  for  those  of  tuber- 
culous disease.  There  may  be,  for  example,  persistent  swelling, 
thickening  of  the  tissues,  limitation  of  motion,  and  deformity 
combined  with  more  or  less  weakness  and  discomfort.  These 
symptoms  are  explained  by  the  irritation  of  the  effused  blood 
and  by  its  further  absorption  and  organization,  which  necessi- 
tates the  formation  and  growth  of  new  bloodvessels  ;  practically, 
a  granulation  tissue  is  formed  that  erodes  the  cartilage  upon 
which  the  fibrinous  deposits  rest.  These  secondary  changes 
resemble  the  early  stage  of  hypertrophic  arthritis. 

Treatment. — The  local  treatment  is  rest  and  protection  com- 
bined with  stimulating  applications  to  hasten  the  absorption  of 
the  effused  blood.  Several  deaths  have  been  reported  from 
^  Deutsch.  Zeit.  f .  Chir.,  Bd.  Ixxvi. 


296  OBTHOPEDIC  SUEGEBY. 

hemorrliage  after  operative  intervention  in  cases  in  v^hich  the 
affection  had  been  mistaken  for  tuberculous  disease. 

HEMARTHROSIS. 

Hemorrhage  into  a  joint  may  occur  in  normal  individuals, 
and  its  presence  is  not  always  indicated  by  superficial  discolora- 
tion. The  swelling  is  more  resistant  than  is  the  ordinary  effu- 
sion, and  it  is  far  more  persistent.  This  suggests  the  advi- 
sability of  incision  and  removal  of  the  blood  clots  in  certain 
instances  in  order  to  relieve  the  joint  of  burden  of  their  organi- 
zation and  absorption. 

SCORBUTUS— SCURVY. 

This  affection  is  sometimes  attended  with  hemorrhage  into 
and  about  the  joints.  It  will  be  considered  in  connection  with 
infantile  rhachitis. 

TABETIC   ARTHOPATHY— CHARCOT'S  DISEASE. 

Disease  of  the  joints  caused  by  tabes  may  occur  in  two  forms, 
a  simple  chronic  synovitis  or  as  a  destructive  osteoarthritis. 
The  latter  is  the  characteristic  form  known  as  Charcot's  disease. 

Pathology. — It  resembles  somewhat  in  its  pathology  hyper- 
trophic arthritis.  The  cartilage  degenerates,  and,  together  with 
the  underlying  bone,  is  worn  away  by  the  movements  of  the  limb. 
Accompanying  the  destructive  process  there  is  an  exaggerated 
and  irregular  formation  of  cartilage  and  bone  about  the  periphery 
of  the  joint.  The  synovial  membrane  is  hypertrophied,  and 
may  be  covered  in  places  with  calcareous  plates;  the  contents 
of  the  joint  are  usually  increased  in  quantity. 

The  joint  disease  often  appears  early  in  the  course  of  loco- 
motor ataxia,  before  its  existence  is  suspected.  It  is  sometimes 
caused  directly  by  injury  but  the  predisposing  cause  is  the  loss 
of  protection  due  to  the  hypotonia  of  the  muscles  and  to  the 
tittitude  of  hyperextension  at  the  knees  which  is  often  habitual. 

In  246  cases  of  arthopathy  analyzed  by  Henderson^  54  of  the 
patients  were  in  the  preataxic  stage,  36  in  the  transitional  and 
in  156  the  ataxia  was  well  marked. 

Charcot's  disease  is  said  to  affect  about  5  per  cent,  of  the 
ataxic  patients ;  it  is  more  common  in  the  lower  extremity,  and 
one  or  more  joints  may  be  involved.  In  the  cases  tabulated  by 
Flatow  the  distribution  was  as  follows : 

•  Path,  and  Bact.,  1905,  v.  10. 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS.  297 

Fig.  204. 


Charcot" s  disease  of  the  knee-joint.     A  useful  support  in  cases  of  this  character 
is    illustrated   in    Fig.    205. 

Knee   60 ;  in  13  cases  both  knees. 

Foot    30 ;  in     9  cases  both  feet. 

Hip    38 ;  in     9  cases  both  hips. 

Shoulder   27;  in     6  cases  both  shoulders.* 

Cliipault"  notes  the  distribution  in  217  cases,  as  follows: 

Knee   120 

Hip 57 

Foot    40 

Fifteen  cases  of  Charcot's  disease  involving  the  spine  have 
been  reported.^ 

Symptoms. — The  symptoms  are  the  swelling  due  to  the  effu- 
sion, laxity  of  the  ligaments,  and  deformity.  There  is  prac- 
tically no  local  pain  or  sensitiveness,  and  the  patient's  chief  com- 
plaint is  of  the  weakness  and  distortion  of  the  limb.  In  certain 
cases  the  progress  of  the  affection  is  very  rapid,  and  the  destruc- 
tion of  bone  may  be  so  extensive  that  there  is  an  actual  luxation 
at  the  affected  joint. 

Diagnosis. — If  the  patient  is  knowni  to  have  locomotor  ataxia 
the  diagnosis  will  be  evident,  and  in  any  event  the  peculiar  en- 
largement, and  thickening  of  the  tissues,  together  with  the  ex- 

'  Deutsche  Chir.,  1900,  vol.  1.,  p.  28. 
-  Le  Dentu  et  Delbet,  Traite  de  Chir. 

^  Abadie.  Nouv.  Icon,  de  la  Salpetriere,  T.  xiii.,  1900.  Cornell.  Johns 
Hopkins  Hosp.  Bull.,  October,  1902. 


298  OBTEOPEDIC  SVEGEEY. 

cessive  laxity  of  the  ligaments,  characteristic  of  this  affection, 
which  has  been  called  a  caricature  of  hypertrophic  arthritis, 
should  call  attention  to  the  disease  of  the  spinal  cord.  Of  this 
the  diagnostic  symptoms  beside  the  ataxia  are  absence  of  tendon- 
jerks  in  the  lower  extremities,  disorders  of  sensation  and 
lessened  muscular  tone,  and  absence  of  reaction  of  the  pupils  to 
light.i 

Treatment. — The  treatment  of  the  local  disease  is  efficient 
support  to  j)reyent  progressive  distortion.  Excision  of  the  knee 
has  been  performed,  but  in  many  cases  the  bones  have  failed  to 
unite,  and  on  this  account  the  operation  is  contraindicated. 

Disease  of  joints  secondary  to  other  forms  of  disease  of  the 
nervous  system  may  occur.  It  is  most  common  as  a  complica- 
tion of  syringomyelia,  19-  cases  of  which  has  been  investigated 
by  Borchard,"  in  which,  in  contrast  to  locomotor  ataxia,  the 
joints  of  the  upper  extremity  are  far  more  often  involved  than 
of  the  lower.  The  symptoms  of  this  affection  are  loss  of  sensa- 
tion to  pain  and  temperature,  disturbance  of  nutrition  and  mus- 
cular atrophy. 

In  Schlesinger's  cases  the  distribution  was  as  follows  :^ 

Shoulder 29 

Elbow   24 

Wrist    18 

Hip    4 

Knee     7 

Foot    7 

Other  joints    8 

97 

In  all  forms  of  joint  disease  secondary  to  disease  of  the  nerv- 
ous system  the  influence  of  injury  on  the  ill-nourished  or  ill- 
protected  part  is  recognized  in  the  causation  and  in  the  progress 
of  the  disease.     This  indicates  the  principles  of  local  treatment. 

ANCHYLOSIS. 

Anchylosis  implies  fixation  iu  an  attitude  of  deformity,  and 
the  term  should  be  restricted  to  practical  fixation  caused  by 
tissue  changes  within  or  without  a  joint.     It  is,  however,  often 

^  According  to  Uhthoif  the  symptoms  of  tabes  in  order  of  frequency  are 
as  follows: 

1.  Disturbances  in  sensibility   (in  the  widest  sense)  .  .  92 

2.  Lancinating  pains    ; 85 

3.  Loss  in  patellar  reflex    83 

4.  Arg^^ll-Eobertson  pupils    79 

5.  Eomberg  phenomenon    71 

6.  Ataxia     55 

2  Deutsche  Zeit.  f.  Chir..  Bd.  Ixxii.,  1904. 

^  Die  Syringomyelie,  Wien,  1895. 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS.  299 

incorrectly  applied  to  limitation  of  motion,  such  as  may  be 
caused,  for  example,  by  muscular  spasm. 

Etiology  and  Pathology. — Anchylosis  is  usually  secondary  to 
an  inflammatory  affection  of  the  joint  during  which  adhesions 
have  formed  within  and  without  the  capsule.  If  deformity  has 
been  allowed  to  persist  the  muscles  on  the  contracted  side  are 
structurally  shortened.  If  the  cartilages  have  been  destroyed, 
bony  union  or  synostosis  often  results.  This  is  sometimes  called 
true,  as  distinguished  from  false  or  fibrous  anchylosis. 

The  latter  form  which  is  far  the  more  common  in  youthful 
patients  may  be  caused  by  adhesions  between  the  folds  of  syno- 
vial membrane,  by  adhesions  and  contractions  of  the  capsular 
and  other  ligaments,  by  adhesions  between  the  tendons  and  their 
sheaths,  by  the  general  adhesions  and  contractions  caused  by 
burrowing  abscesses,  and  by  structural  shortening  of  the  muscles 
when  the  deformity  has  persisted  for  a  sufficient  time.  It  may 
be  caused,  also,  by  fractures  or  dislocations  or  by  marginal 
exostoses. 

Prevention  and  Treatment. — The  danger  of  anchylosis  may 
be  lessened  by  the  proper  treatment  of  the  disease  of  which  it 
is  a  result.  In  tuberculous  disease,  for  example,  motion  may  be 
preserved  in  many  instances  by  efiicient  protection,  by  which  the 
area  of  the  disease  is  restricted  and  its  destructive  effects 
checked.  In  this  class  of  cases  the  joint  should  be  fixed  during 
the  progressive  stage  of  the  disease,  in  the  attitude  in  which 
anchylosis,  if  it  be  unavoidable  will  least  inconvenience  the 
patient,  and,  if  possible,  efficient  traction  should  be  employed 
with  the  aim  of  separating  the  surfaces  of  the  adjoining  bones. 

Formerly  it  was  believed  that  prolonged  fixation  of  a  diseased 
joint  would  of  itself  induce  anchylosis,  but  now  that  it  is  known 
that  final  limitation  of  motion  is  dependent  upon  the  severity 
and  the  duration  of  the  disease,  prolonged  rest  is  believed  to  be 
the  most  efficient  means  of  assuring  movement. 

Although  long  continued  splinting  of  a  joint  causes  temporary 
fixation  yet  as  a  rule  functional  use  will  restore  all  the  motion 
of  which  the  part  is  capable.  In  other  infiammatory  affections 
of  the  joint  the  violence  of  the  inital  process  may  be  restrained 
by  the  local  application  of  cold  or  heat,  or  by  the  removal  of  the 
contents  of  the  joints  if  the  infection  is  severe.  In  all  cases  the 
joint  should  be  properly  supported  in  order  to  relieve  pain  and 
to  prevent  deformity. 

Passive  Motion. — When  the  acute  symptoms  have  subsided  the 
absorption  of  the  plastic  material  may  be  hastened  by  massage, 


300 


OETHOPEDIC  SUEGEEY. 


tlie  hot-air  batli,  and  the  like,  and  by  carefully  regulated  passiye 
and  actiye  motion.  Passiye  congestion  after  the  method  of 
Bier  is  also  of  yalue.^  In  the  final  stage,  when  there  is  no  longer 
evidence  of  active  disease,  passive  movements  under  anaesthesia 
may  he  of  service  in  breaking  adhesions,  especially  if  these  are 
without  the  joint.     Passive  movements  that  cause  persistent  dis- 

FiG.  205. 


A   useful   form   of  brace  for  weak  knee,   in  which   the   range   of  motion   is   regu- 
lated by  means  of  an  adjustable  wheel.      (Shaffer.) 

comfort  or  pain,  which  are  often  employed  in  the  treatment  of 
stiif  joints,  even  when  the  disease  is  active,  are  absolutely  contra- 
indicated.  If,  however,  the  limb  during  the  course  of  the  disease 
has  become  deformed,  it  should  be  restored  to  its  proper  position 
as  soon  as  possible,  even  though  force  is  required.  This  treat- 
ment is  indicated  in  order  to  prevent  or  to  overcome  secondary 
retraction  of  the  muscles  and  fasciae. 

^  Blecher,  Deutsche  Zeits.  f.  Chir.,  Bd.  Ix.,  p.  250. 


NON-TUBEECULOUS  DISEASES  OF  THE  JOINTS. 


301 


Fig.  206. 


Forcible  Correction. — The  class  of  cases  in  which  the  limb  has 
become  fixed  in  deformity  is  the  most  favorable  one  in  which  to 
perform  the  so-called  brisement  force,  because  the  rectification 
of  deformity  is  always  indicated,  and  in  accomplishing  this 
there  is  always  the  prospect  of  re- 
gaining a  certain  degree  of  motion. 
If,  however,  there  is  no  deformity 
the  advisability  of  forced  movement 
will  depend  on  the  character  of  the 
preceding  disease  as  well  as  upon 
the  condition  of  the  joint.  It  is 
rarely  advisable  to  disturb  a  tuber- 
culous joint  except  for  the  purpose 
of  correcting  deformity,  at  least  not 
until  long  after  the  cure  of  the  dis- 
ease ;  but  if  the  anchylosis  has  fol- 
lowed infectious  arthritis  of  a  mild 
form,  or  monarticular  "  rheuma- 
tism," forcible  manipulation  may 
be  attempted.  If  under  gentle 
manipulation  the  adhesions  give 
way  suddenly,  permitting  free  mo- 
tion, the  progTiosis  is  good ;  but  if 
there  is  a  peculiar,  elastic,  con- 
tinuous resistance,  as  when  there  are 
extensive  adhesions  within  the  joint, 
there  is  little  likelihood  of  attaining 
motion  by  this  means.  If  but  slight 
force  has  been  exerted  there  is  usu- 
ally but  little  reaction,  and  massage 
and  passive  motion  may  be  em- 
ployed at  once ;  but  in  other  in- 
stances the  manipulation  is  followed 
by  swelling  and  pain,  and  until 
these  symptoms  have  subsided  fixa- 
tion may  be  indicated.  It  may  be 
mentioned  that  anchylosis  follow- 
ing disease  is  usually  accompanied 
by  marked  atrophy  of  the  bones,  and  fracture  may  occur  during 
forcible  correction.  In  cases  of  this  character  the  complication 
of  fat  embolism  is  sometimes  encountered.  If  the  deformity  is 
of  long  standing  complete  correction  should  not  be  attempted  at 


Anchylosis  at  the  hip,  showing 
masses  of  new  bone.  (From  the 
Museum  of  the  College  of  Physi- 
cians and   Surgeons.) 


302  OETHOPEDIC  SUBGEBY. 

one  sitting.  At  the  knee  for  example  the  hamstring  tendons  may 
be  divided  and  the  deformity  having  been  partly  corrected  a 
j)laster  bandage  should  be  applied.  After  an  interval  of  a  week 
or  more  further  correction  is  attempted  by  "  reverse  leverage  " 
as  described  elsewhere.  If  the  resistance  can  not  be  readily 
overcome  a  subcutaneous  osteotome  is  inserted  just  above  the 
joint  and  the  correction  is  made  complete  by  fracturing  the 
femur.  In  cases  of  bony  anchylosis  in  youthful  patients  even 
right  angular  deformity  should  be  corrected  by  osteotomy  rather 
than  by  removal  of  a  wedge  of  bone  which  must  include  the 
epiphyseal  cartilages. 

After  subsidence  of  the  reaction  that  usually  follows  forcible 
correction,  passive  movements  within  the  range  that  is  practi- 
cally painless  may  be  carried  out  manually,  or  by  means  of  one 
of  the  so-called  pendulum  machines,  by  which  the  limb  is  moved 
back  and  forth  at  frequent  intervals  until  the  part  is  fatigued. 
Functional  use,  when  the  joint  is  protected  by  apparatus  that 
limits  the  range  of  motion  to  the  painless  area,  is  also  of  service. 

The  X-ray  may  be  of  value  in  demonstrating  the  condition 
of  the  joint  and  the  degree  of  atrophy  of  the  bones,  but  the 
history,  which  should  indicate  the  character  of  the  disease,  and 
the  physical  examination  are  far  more  reliable  from  the  stand- 
point of  prognosis.  In  some  instances  operative  exploration  of 
the  joint  may  be  indicated.  This  permits  the  removal  of 
exostoses  or  displaced  fragments  of  bone  after  fracture  that  may 
limit  motion  mechanically.  Recently  the  attempt  has  been  made 
to  prevent  reunion  of  the  surfaces  of  the  adjoining  bones  by  the 
insertion  of  thin  plates  of  magnesium  or  other  absorbable 
material,  the  latest  being  especially  prepared  pig's  bladder 
recommended  by  Baer,  as  one  prevents  union  in  smaller  joints 
by  interposing  muscular  or  other  tissue.  As  yet  the  method  is 
in  the  experimental  stage. 

Murphy,^  of  Chicago,  has  reported  a  number  of  cases  treated 
by  interposition  of  flaps  of  fibrofatty  tissue.  At  the  knee,  for 
example,  the  joint  is  exposed  by  long  lateral  incisions.  The 
capsule  is  then  removed,  only  the  lateral  ligaments  being  pre- 
served. The  bones  are  then  separated  completely,  obstructions 
to  movement  cut  away,  and  broad  flaps  of  fibromuscular  tissue 
from  the  lateral  aspect  of  the  muscles  on  one  or  both  sides  of  the 
joint  are  turned  down  and  are  inserted  between  the  bones  and 
beneath  the  patella  if  this  is  adherent.  The  skin  is  then  united. 
Later  massage  and  passive  motion  are  employed. 

'  Journal  of  the  American  Medical  Association,  May.  1905. 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS.  303 

This  operation  may  be  of  service  in  certain  carefully  selected 
cases  particularly  those  in  which  the  destruction  of  tissue  has 
been  slight  and  in  which  the  patella  is  free.  As  a  rule,  however, 
at  least  in  the  working  class,  an  anchylosed  joint  of  the  lower 
extremity  is  far  more  serviceable  than  one  in  which  a  few  de- 
grees of  motion  persist  or  in  which  a  wider  range  is  limited  by 
obstructions  within  the  joint.  For  whenever  the  joint  is  strained 
by  an  unguarded  movement  the  patient  suffers  discomfort,  and 
motion  uncontrolled  by  the  muscles,  as  in  the  cases  in  which  the 
patella  is  fixed,  is  worse  than  useless.  Operations  of  this  class 
are  far  more  successful  in  the  upper  than  in  the  lower  or  weight- 
bearing  extremity,  because  as  stability  is  not  essential  sufficient 
bone  may  be  removed  to  prevent  reunion. 

At  the  ankle-joint  removal  of  the  astragalus  will  often  restore 
motion,  and  at  the  hip  excision  may  be  advisable  if  both  joints 
are  fixed. 

MALIGNANT  DISEASE  OF  BONE. 

Carcinoma  is  almost  always  secondary  to  disease  elsewhere. 
Sarcoma  is  usually  a  primary  disease.  Its  seat  of  election  is 
near  the  extremities  of  the  long  bones,  thus  it  is  often  mistaken 
for  disease  of  the  neighboring  joint.  It  is  far  more  common  in 
the  lower  than  in  the  upper  extremity  and  in  50  per  cent,  of  the 
cases  the  femur  is  involved.-^ 

The  tumor  may  be  periosteal  or  central.  If  periosteal  its 
outline  is  irregular.  If  central  the  bone  is  more  uniformly 
enlarged.  In  some  instances,  the  pain,  sensitiveness  and  swell- 
ing induced  apparently  by  injury  simulate  very  closely  disease 
of  the  joint.  As  a  rule,  however,  the  disease  of  the  bone  is  more 
marked  than  that  of  the  joint  and  an  X-ray  picture  will  indi- 
cate its  destructive  character. 

^  Coley,  Annals  of  Surgery,  March,  1907. 


CHAPTER  VII. 

TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


Synonyms.— Hip  disease,  morbus  coxse. 

Hip  disease  is  a  chronic  destructive  disease  that  results  in  loss 
of  function  and  deformity.  At  one  time  a  number  of  patho- 
logical processes  and  even  simple  deformity  (coxa  vara)  were 
included  under  the  title,  but  it  is  now  limited  to  tuberculous 
disease. 

Pathology. — Tuberculous  disease  of  the  hip-joint  usually  be- 
gins in  several  minute  foci  near  the  epiphyseal  cartilage  of  the 

Fig.  207. 


Section  of  the  hip-joint  at  the  age  of  eight  years,  showing  the  epiphyses  and 
the  relation  of  the  capsule.  (Schuchardt.)  At  birth  the  entire  upper  extremity 
of  the  femur  is  cartilaginous.  According  to  Jacinsky,  ossification  begins  in  the 
head  of  the  femur  at  about  the  tenth  month ;  in  the  trochanter  major  at  from 
the  fourth  to  the  eighth  year ;  in  the  trochanter  minor  at  the  eleventh  year. 
Ossification  is  complete  at  all  points  at  about  the  eighteenth  year.  Range  of 
motion  at  the  hip-joint.  Extension  to  20  degrees  beyond  the  horizontal ;  flex- 
ion to  70  degrees ;  total  140  degrees.  Abduction,  adduction,  and  rotation  are 
most  free  when  the  limb  is  flexed  to  130  degrees.  At  this  point  the  range  of 
abduction  is  55  degrees,  of  adduction  35  degrees;  total  90  degrees.  Outward 
rotation  40  degrees,  inward  rotation  20  degrees;  total  60  degrees.  If  the  limb 
Is  completely  extended  the  range  of  abduction  is  about  45  degrees ;  adduction, 
15  degrees.^ 

'  E.  du  Bois-Eaymond,  Berlin,  1903. 

304 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


305 


Fig.  208. 


head  of  the  femur.  Here  the  circulation  is  most  active,  and 
here  the  newly-formed  bone  is  least  resistant.  Thus  the  bacilli, 
carried  by  the  blood,  are  more  often  deposited  at  this  point, 
where,  under  favoring  conditions,  the  disease  is  established. 
These  foci  coalesce  and  an  area  of  infected  granulations  replaces 
the  normal  structure.  If  the  local  resistance  is  sufficient  the 
disease  may  be  confined  to 
the  interior  of  the  bone,  but 
in  most  instances  it  gradually 
forces  its  way  into  the  joint 
and  the  granulation  tissue, 
spreading  under  and  over  the 
cartilage,  destroys  it  in  its 
progress.  The  lining  mem- 
brane of  the  joint  becomes 
involved  in  the  disease,  and, 
finally,  the  adjoining  surface 
of  the  acetabulum  as  well. 
In  a  certain  indeterminate 
number  of  cases  the  tubercu- 
lous process  begins  about  the 
epiphyseal  junctions  of  the 
acetabulum,  and  primary  dis- 
ease of  the  synovial  mem- 
brane may  occur,  although 
this  is  certainly  uncommon 
in  childhood. 

From  the  clinical  stand- 
point, primary  disease  of  the 
acetabulum  may  be  inferred 
if  the  patient  is  particularly 
susceptible  to  movements  of 
the  trunk,  or  if  lateral  pres- 
sure on  the  pelvis  causes  pain ;  or  if  a  Koentgen  picture  shows 
greater  erosion  of  the  acetabulum  than  of  the  head  of  the  femur 
(Fig.  209).  There  are  other  cases  in  which  the  symptoms  of 
the  disease  are  slight  and  in  which  swelling  about  the  joint  is 
noticeable ;  in  such  cases  it  is  probable  that  disease  of  the  syno- 
vial membrane  is  present  without  marked  involvement  of  the 
head  of  the  femur  or  of  the  acetabulum. 

In  the  common  or  osteal  form  of  disease,  while  the  tuber- 
culous process  is  still  confined  within  the  head  of  the  femur, 
20 


Wandering  of  the  acetabulum 
disease.      (Krause.) 


in  hip 


306 


OETHOPEDIC  SUBGEET. 


the  joint  shows  evidences  of  sympathetic  irritation;  the  synovial 
membrane  is  congested,  and  the  ilnid  within  the  joint  is  in- 
creased in  quantity.  These  changes  become  more  marked  as  the 
disease  progresses,  the  lining  membrane  becomes  thickened  and 
granular,  and  adhesions  between  its  folds  lessen  the  capacity  of 
the  joint.     An  amount  of  tuberculous  fluid,  large  enough  to  be 

Fig.  209. 


Erosion   of  the  head  of  the  femur  and  of  the  upper  border   of  the  acetabulum. 
Formation  of  new  bone    (osteophytes)   about  the  acetabulum. 


recognized  as  an  "  abscess,"  is  present  in  about  half  the  cases  at 
some  time  during  the  course  of  the  disease.  This  fluid  usually 
finds  an  exit  from  the  capsule  into  the  tissues  of  the  thigh,  but 
occasionally  it  may  pass  through  the  acetabulum  into  the  pelvis. 
In  rare  instances  the  disease  may  not  enter  the  joint,  but  may 
find  an  02:)ening  in  the  neck  through  the  adherent  capsule.  In 
such  cases  the  joint  is,  in  most  instances,  finally  involved  unless 
the  disease  is  removed  by  surgical  means.  There  are  cases, 
also,  in  which  the  disease,  confined  within  the  head  of  the  bone, 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


307 


SO  weakens  it  that  it  becomes  distorted  to  a  marked  degree  with- 
out destruction  of  the  cartilage. 

If  the  disease  involves  the  neck  of  the  bone  it  may  sink  down- 
ward, a  form  of  coxa  vara ;  or  the  head  of  the  bone  may  be 
separated  at  the  epiphyseal  junction,  with  consequent  upward 
displacement  of  the  shaft. 

In  by  far  the  larger  number  of  cases  the  joint  is  perforated 
and  the  head  of  the  femur  and  the  acetabulum  are  eroded  to  a 
greater  or  less  degree.     In  such  instances  the  destructive  effects 

Fig.  210. 


Erosion   of  the  head  of  the  femur  and   of  the  upper  margin   of  the  acetabulum^ 
Aj  anterior  superior  spine.     B^  anterior  inferior  spine. 


of  the  disease  are  increased  by  the  pressure  and  friction  of  the 
softened  bones  on  one  another,  aggravated  by  the  spasm  of  the 
surrounding  muscles.  Thus  at  the  upper  margin  of  the  acetabu- 
lum and  the  inner  and  upper  surface  of  the  femur  there  is 
greater  loss  of  substance  than  elsewhere  (Fig.  209). 

The  appearances  in  advanced  cases  of  this  type,  as  seen  at 
operation  or  autopsy,  may  be  summarized  as  follows :  The  head 
of  the  femur  is  deeply  eroded,  its  cartilaginous  covering  has 
practically  disappeared,  or  is  in  part  still  adherent  in  necrotic 
shreds.    It  lies  in  seropurulent  fluid,  embedded  in  the  gelatinous 


308 


OBTHOPEDIC  SUBGEBY. 


granulations  that  line  the  capsule  and  j)artly  fill  the  acetabulum. 

In  certain  instances  the  disease  may  extend  to  the  adjoining 
surface  of  the  pelvis,  or  the  acetabulum  may  be  perforated  (Fig. 
211),  or  the  medullary  cavity  of  the  femur  may  be  implicated. 
Occasionally  the  disease  may  be  from  the  first  of  an  acute  de- 
structive type,  v^hose  course  is  but  little  influenced  by  treatment, 
but  in  the  majority  of  cases  the  progress  of  the  disease  and  its 
destructive  effects  may  be  greatly  modified  by  efficient  protection 
of  the  joint. 

In  the  natural  cure  of  the  disease  the  focus  within  the  bone,  if 
it  be  small,  may  be  absorbed  and  replaced  by  scar-like  tissue ;  or 
the  products  of  the  disease  may  be  separated  from  the  healthy 
parts,  and  discharged  by  abscess  formation.  In  other  instances 
a  part  in  v^hich  the  disease  is  still  active  may  be  enclosed  within 
the  newly-formed  tissue.  Here  the  process  may  remain  quies- 
cent or  it  may  cause  relapse,  many  years  after  the  apparent 
cure.  Or  portions  of  necrosed  bone,  enclosed  within  the  capsule, 
may  prolong  suppuration  after  the  tuberculous  disease  has 
ceased  to  progress. 

Etiology. — The  etiology  of  tuberculous  disease  is  discussed  in 
Chapter  V. 

Relative  Frequency. — Tuberculous  disease  of  the  hip-joint  is 
the  most  common  and  the  most  important  of  the  affections  of  the 
joints,  ranking  second  to  Pott's  disease.  In  a  total  of  7845  cases 
of  tuberculous  disease  treated  in  the  out-patient  department  of 
the  Hospital  for  Euptured  and  Crippled  during  a  period  of 
fifteen  years  3203  were  Pott's  disease,  2230  were  hip  disease, 
while  the  remaining  2412  cases  included  all  the  other  joints. 


Age  at  Incipiency. 


Less  than 

Between 

Between 

Between 

Between 

Between 

Between 

Between 

Between 

Between 

Between 

Between 

Between 

Between 

Between 

Between 


year 
and 
and 
and 
and 
and 
and 

7  and 

8  and 

9  and 

10  and 

11  and 

12  and 

13  and 

14  and 

15  and 


2  years. 

3  years. 

4  years. 

5  years. 

6  years. 

7  years. 

8  years. 

9  years. 

10  years. 

11  years. 

12  years. 

13  years. 

14  years. 

15  years. 

16  years. 


9 

Between 

39 

Between 

107 

Between 

155 

Between 

158 

Between 

139 

Between 

90 

Between 

51 

Between 

51 

Between 

40 

Between 

33 

Between 

19 

Between 

18 

Between 

23 

Between 

7 

Between 

8 

Age  not 

16  and 

17  and 

18  and 

19  and 

20  and 

21  and 

22  and 

23  and 

24  and 

25  and 

26  and 

27  and 

28  and 
30  and 
33  and 
stated. 


17  years. 

18  years. 

19  years. 

20  years. 

21  years. 

22  years. 

23  years. 

24  years. 

25  years. 

26  years. 

27  years. 

28  years. 

29  years. 
33  years. 
36  years. 


11 
4 
5 
0 
3 
3 
1 
2 
3 
1 
1 
1 
1 
4 
1 
_12 
1000 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


309 


Age.— Hip  disease  is  essentially  a  disease  of  early  childhood, 
although  no  age  is  exempt.  In  a  series  of  1000  consecutive  cases 
of  hip  disease  tabulated  for  me  by  Ashley,  formerly  an  assistant 
in  the  department,  88.1  per  cent,  of  the  patients  were  in  the  first 
decade  of  life,  and  45.6  per  cent,  of  these  were  from  three  to  five 
years  of  age,  inclusive. 

Sex. — Sex  exercises  but  little  influence  in  predisposition, 
although  the  disease  is  slightly  more  common  among  males  than 
among  females.  In  the  1000  cases  referred  to,  553  (55.3  per 
cent.)  were  in  males,  447  were  in  females. 

In  3307  cases  treated  at  the  same  institution,  53  per  cent, 
were  in  males. 

Side  Affected. — In  disease  of  this  as  of  other  joints  the  right  is 
somewhat  more  often  affected  than  the  left.     In  the  1000  cases 

Fig.  211. 


Erosion  of  the  head  of  the  femur  and  destruction  of  the  acetabulum. 

506  were  on  the  right  side,  483  were  on  the  left,  and  in  11  cases 
both  joints  were  involved.  In  a  larger  number  of  cases  treated 
in  the  department  53  per  cent,  were  of  the  right  joint. 

Symptoms. — Tuberculous  disease  of  the  hip-joint  is  a  chronic, 
insidious  affection  characterized  by  painful  periods  often  in- 
duced by  overstrain  or  injury,  or  that  indicate  more  rapid 
advance  of  the  destructive  process,  or  infection  with  pyogenic 
germs.     In  the  early  stage  of  the  disease  the  joint  is  simply 


310  OBTHOPEDIC  SUBGEBY. 

sensitive,  and  the  symptoms  vary  with  the  increase  of  the  tension 
within  the  bone,  the  susceptibility  of  the  patient,  and  the  strain 
to  which  the  weakened  part  is  subjected.  This  sensitiveness  is 
first  indicated  by  the  involuntary  adaptation  of  the  body  to  the 
weakness  of  the  affected  joint,  or,  as  popularly  expressed,  the 
patient  favors  the  limb. 

The  important  symptoms  of  disease  of  the  hip-joint,  in  the 
sense  of  attracting  attention  to  the  affection,  are  jjain  and  limp. 
Of  the  two,  pain  is  much  the  less  significant.  Hip  disease  is  by 
no  means  a  painful  disease,  and  although  patients  are  often 
brought  for  treatment  because  of  pain,  it  is  usually  apparent, 
on  examination,  that  the  disease  must  have  existed  long  before 
the  acute  exacerbation  called  attention  to  its  serious  character. 
Even  in  cases  in  which  the  disease  is  far  advanced,  one  may  be 
assured  that  the  patient  has  never  complained  of  pain. 

Pain. — The  characteristic  pain  of  hip  disease  is  "pain  in  the 
knee,"  referred,  as  is  the  pain  of  Pott's  disease,  to  the  more 
important  distribution  of  the  nerves,  whose  filaments  are  irri- 
tated by  the  local  process.  The  hip-joint  is  supplied  by  the 
anterior  crural,  the  sciatic,  and  the  obturator  nerves,  but  the 
pain  is  more  often  referred  to  the  distribution  of  the  last,  thus 
to  the  inner  side  of  the  knee. 

The  pain  of  hip  disease  is  induced  by  sudden  or  unguarded 
movements,  or  by  over  use ;  therefore,  it  is  rather  an  occasional 
than  a  constant  symptom.  If  it  is  persistent  it  almost  always 
indicates  the  increased  tension  either  within  the  bone  or  within 
the  joint  that  accompanies  abscess  formation. 

ISTiGHT  Cry. — Pain  at  night  is  of  importance,  as  it  more  often 
attracts  attention  than  the  occasional  complaint  of  discomfort 
during  the  day.  It  is  a  common  symptom  when  the  disease  is 
at  all  acute  in  character,  and  it  is  often  present  when  pain,  dur- 
ing the  period  of  activity,  is  apparently  absent.  It  may  be 
inferred,  as  an  explanation  of  this  symptom,  that  the  joint 
gradually  becomes  more  sensitive  under  the  strain  of  use  during 
the  day,  and  that  the  relaxation  of  the  voluntary  and  involuntary 
protection  of  the  muscles  permits  sudden  movements  tiiat  excite 
spasmodic  muscular  contractions,  which  force  the  sensitive  parts 
against  one  another.  This  causes  a  sharp  cry.  If  the  disease 
is  acute,  it  may  be  noted  that  the  child  is  holding  the  thigh  with 
the  hands  or  pressing  upon  the  limb  with  the  other  foot,  the 
evidence  of  pain  being  unmistakable..  In  the  less  sensitive  con- 
ditions the  patient  does  not  wake  after  crying  out,  but  simply 


TUBEECULOUS  DISEASE  OF  THE  RIP-JOINT.  311 

moans  or  is  restless  for  a  time.  If  awakened  it  makes  no  com- 
plaint of  pain  and  the  cry  is  supposed  to  be  caused  by  a  "  bad 
dream."  This  cry  may  be  repeated  several  times,  usually  in  the 
early  part  of  the  night. 

Direct  local  pain  and  sensitiveness  to  pressure  are  unusual 
unless  the  disease  is  acute  in  character,  or  unless  the  tissues 
overlying  the  joint  are  infiltrated,  as  in  abscess  formation. 

Limp. — The  limp  is  the  most  important  of  what  may  be  classed 
as  the  preliminary  signs  of  the  disease.  A  limp  is  a  change  in 
the  rhythm  of  the  gait,  the  step  being  relatively  shorter  on  the 
affected  side.  It  is  evident  that  any  interference  with  the  func- 
tion of  the  limb  will  cause  this  irregularity  which  can  be  con- 
cealed or  diminished  only  by  accommodating  the  normal  mem- 
ber to  its  disabled  fellow.  Thus  inequality  in  length  of  the 
limbs  or  limitation  of  motion  in  the  joint,  or  distortion,  or  weak- 
ness or  pain,  may  cause  an  arrhythmical  gait.  Several  of  these 
factors  may  be  combined  in  the  causation  of  the  final  disability 
of  hip  disease,  but  in  the  beginning,  the  limp  is  due  rather  to 
sensitiveness  than  to  restriction  of  function.  Thus  the  patient 
favors  the  joint  by  resting  on  the  limb  for  a  shorter  time  than 
on  its  fellow,  and  by  bearing  more  weight  upon  the  front  of  the 
foot  than  upon  the  heel.  If  the  joint  is  very  sensitive,  the 
patient  may  bear  practically  all  the  weight  upon  the  front  of 
the  foot,  the  slight  plantar  flexion  at  the  ankle  with  flexion  at 
the  knee  and  hip;  lessening  the  jar  of  direct  impact. 

The  limp  is  practically  a  constant  symptom  of  hip  disease; 
it  is  as  a  rule  more  noticeable  in  the  morning  or  on  changing 
from  an  attitude  of  rest  than  during  activity.  It  may  be  inter- 
mittent even,  although  it  is  probable  that  in  most  instances  some 
change  from  the  normal  gait  might  be  detected  by  a  practised 
eye. 

Physical  Signs.^The  other  symptoms  of  disease  of  the  hip- 
joint  are  more  properly  physical  signs  that  become  evident  on 
examination.  These  are:  stiffness,  distortion,  change  of  contour, 
and  atropliy. 

Stiffness. — Stiffness,  due  to  reflex  muscular  spasm,  is  by  far 
the  most  important  sign  of  the  disease.  It  indicates  that  the 
sensitive  tissues  of  the  joint  can  no  longer  permit  the  full  range 
of  motion.  It  is  the  first  and  the  last  sign  of  disease ;  it  pre- 
cedes the  limp,  and  it  persists  long  after  pain  has  ceased  to  be 
a  symptom,  and  until  repair  is  complete. 

Reflex  muscular  spasm  limits  motion  in  every  direction.     At 


312  OBTHOPEDIC  SUEGEBY. 

an  early  stage  of  the  disease  the  motion,  whether  volnntary  or 
passive,  may  be  perfectly  free  to  the  last  quarter  of  its  normal 
range,  where  it  is  checked  by  a  peculiar  elastic  resistance.  If 
an  attempt  is  made  to  force  the  limb  beyond  the  limit  set  by  the 

Fig.  212. 


Apparent  lengthening.  Fixed  abduction  of  45°.  Wlien  tlie  anterior  superior 
spines  are  on  the  same  plane,  as  in  the  illustration,  the  deformity  is  evident. 
(See  Fig.  21.3.) 

muscular  resistance  the  pelvis  follows  the  movement.  The 
contraction  of  the  surrounding  muscles,  including  those  of  the 
trunk  even,  may  be  appreciated  by  the  eye  and  by  the  hand,  and 
the  patient's  expression  is  one  of  discomfort  and  apprehension. 
The  degree  of  muscular  spasm  corresponds  to  the  sensitiveness 
of  the  joint  rather  than  to  the  extent  of  the  disease.     Thus  it 


TUBEECULOUS  DISEASE  OF  TEE  EIP-JOINT. 


313 


may  vary  from  day  to  day  and  even  from  hour  to  hour,  and  in 
the  acute  phases  of  the  disease  motion  may  be  for  a  time  so 
absolutely  restricted  as  to  simulate  anchylosis. 

Reflex  muscular  spasm  is  evidence  of  a  sensitive  joint;  it  is, 
of  course,  not  diagnostic  of  the  tuberculous  process,  but  unless 


Fig.  213. 


Fig.  214. 


Apparent  lengthening.  When  the 
abducted  limb  is  brought  to  the 
median  line  the  pelvis  is  so  tilted  that 
it  seems  longer.      (See  Pig.  212.) 


Right  angular  flexion  in  hip  disease 
partly  concealed  by  the  compensatory 
lordosis  and  by  the  flexion  at  the  knee 
and  ankle. 


it  is  the  direct  effect  of  injury  it  indicates  disease,  and  if  this 
disease  is  chronic  and  confined  to  a  single  joint  it  is,  in  childhood 
at  least,  almost  always  tuberculous  in  character.  At  first  the 
restriction  of  motion  is  caused  almost  entirely  by  reflex  muscular 


314 


ORTHOPEDIC  SUBGEBY. 


spasm,  as  is  shown  by  the  fact  that  when  the  patient  is  anaes- 
thetized the  range  of  motion  becomes  practically  free.  As  the 
destructive  process  progresses  motion  is  still  further  restrained 
by  adhesions  and  contractions  within  and  without  the  joint. 

Distortion  of  the  Limb. — -Persistent  reflex  muscular  spasm  is 
always  accompanied  by  a  certain  change  in  the  attitude  of  the 
limb,  slight  flexion  being  the  earliest  indication  of  distortion 
here  as  at  every  other  joint.  With  flexion  ther^  is  ^usually  ab- 
duction with  slight  outward  rotation  of  the' limb. 

Flexion^  Abduction,  and  Outward  Rotation.  Apparent 
Lengthening. — This  is  the  passive  attitude  or  the  attitude  of 
rest  and  in  disease  it  shows  the  instinctive  adaptation  of  the 
limb  to   a  sensitive  joint  which  is  still  capable  of  a  certain 

Fig.  215. 


The  degree  of  fixed  flexion  is  shown  when  the  lumbar  spine  is  held  in   contact 
with   the   table   by   flexing   the   other   thigh. 


amount  of  work.  Flexion  lessens  the  direct  jar  and  abduction 
places  the  limb  aside,  as  it  were,  making  it  a  prop  and  adjunct 
of  its  fellow  instead  of  an  active  aid  in  the  propulsion  of  the 
body.  This  attitude  is  not  voluntarily  assumed  by  the  patient ; 
it  is  involuntary  and  persistent.  The  limb  is  apparently 
lengthened,  because  it  is  held  away  from  the  axis  of  the  body, 
and  in  order  to  bring  it  into  the  middle  line  and  parallel  to  its 
fellow  the  pelvis  must  be  tilted  downward  on  the  diseased  side 
and  upward  on  the  other.  The  sound  limb  is  drawn  upward 
and  the  affected  limb  is  lowered  according  to  the  degree  of  ab- 
duction for  which  compensation  is  made  (Fig.  213).  If  the 
anterior  superior  spines  of  the  pelvis  are  placed  upon  the  same 
plane,  the  distortion  becomes  evident    (Fig.   212).     Thus  the 


TUBERCULOUS  DISEASE  OF  THE  EIP-JOINT.  315 

deformity  of  the  limb  is  concealed  or  compensated  by  a  tilting 
of  the  pelvis  which  twists  the  Inmbar  spine  into  a  lateral  con- 
vexity toward  the  lower  side. 

In  the  same  manner  persistent  flexion  of  the  limb  is  concealed 
by  tilting  of  the  pelvis  forward,  and  by  an  increased  hoUowness 
or  lordosis  of  the  lumbar  region  (Fig.  214).  l^ormally,  in 
childhood  at  least,  the  lumbar  spine  and  the  popliteal  surface 
of  the  knee  should  touch  the  table  when  the  patient  lies  upon  the 
back ;  but  if  the  thigh  is  fixed  in  flexion  the  lumbar  region  must 
be  arched  and  raised  from  the  table  when  the  limb  is  in  contact 
with  it.  Thus,  in  order  to  make  the  flexion  apparent,  the  lum- 
bar spine  must  rest  upon  the  table,  and  this  is  possible  only  when 
the  limb  is  raised  to  a  degree  corresponding  to  the  deformity 
(Fig.  215).  If  the  spine  were  rigid,  as  in  spondylitis  de- 
formans, this  compensation  would  be  impossible,  and  if  the 
patient  were  placed  upon  his  back  the  limb  could  not  be  brought 
down  to  the  table;  or  if  both  limbs  were  distorted,  as  is  some- 
times the  case  when  both  hip-joints  are  diseased,  the  limbs  would 
remain  widely  separated  or  crossed  over  one  another,  according 
to  the  character  of  the  deformity. 

Flexion,  Adduction,  and  Inward  Rotation.  Apparent 
Shortening. — If  the  disease  is  of  a  more  acute  type,  and  if 
locomotion  be  permitted,  the  attitude  usually  changes  to  one  of 
increased  flexion ;  and  adduction  and  inward  rotation  replace 
abduction  and  outward  rotation.  This  attitude  is  an  indication 
that  the  joint  is  so  disabled  as  to  be  of  little  service,  thus  the  limb 
is  instinctively  drawn  into  a  more  protected  attitude,  where  it 
may  be  used  as  little  as  possible.  If  the  patient  is  confined  to 
the  bed,  or  does  not  walk,  as  in  infancy,  the  attitude,  of  abduc- 
tion may  persist,  although  the  muscular  spasm  may  be  intense. 
Thus  it  would  appear  that  locomotion  has  a  distinct  influence 
on  the  character  of  the  distortion. 

Adduction  causes  apparent  or  practical  shortening;  for  in 
order  to  bring  the  adducted  limb  to  the  middle  line  of  the  body 
and  parallel  to  its  fellow,  the  pelvis  must  be  tilted  upward  on 
the  affected  side  and  downward  on  the  other,  the  lumbar  spine 
bending  with  the  convexity  toward  the  lower  side  (Figs.  217 
and  220).  If  the  level  of  the  pelvis  be  restored,  the  adducted 
limb  will  be  crossed  over  its  fellow  and  the  deformity  is  made 
evident  (Fig.  216). 

As  has  been  stated,  the  attitude  of  flexion,  adduction,  and 
inward  rotation,  if  it  appears  early,  is  usually  an  indication 


316 


ORTHOPEDIC  SUBGEEY. 


of  acute  disease  and  of  corresponding  intensity  of  muscular 
spasm.  But  in  most  instances  it  is  associated  with  tlie  later 
and  destructive  stage  of  the  disease,  and  it  by  no  means  indi- 


FiG.  216. 


Fig.  217. 


Apparent  shortening.  The  adduc- 
tion of  the  right  thigh  is  made  evident 
by  the  involuntary  crossing  of  the 
legs  when  the  anterior  superior  spines 
are  on  the  same  plane. 


Apparent  shortening.  When  the  ad- 
ducted  limb  is  placed  in  the  line  of 
the  body,  the  pelvis  is  tilted  upward 
on  the  adducted  side  and  downward 
on  the  other.  The  patient  has  com- 
pensated for  the  apparent  shortening 
by  flexing  the  knee  on  the  sound  side. 
This  does  not  appear  in  the  photo- 
graph. 


cates  that  the  preceding  symptoms  have  been  more  than  ordi- 
narily acute.  In  fact,  it  is  the  attitude  characteristic  of  a  so- 
called  "natural  cure"  (Fig,  218)  when  mechanical  treatment 
has  not  been  employed.     It  more  often  acompanies  the  later 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  317 

course  of  the  disease,  because  its  causes  are  in  great  degree 
mechanical. 

This  is  illustrated  by  Koenig's  statistics  of  499  cases  of  hip 
disease. 

In  267  cases  the  limb  was  abducted,  and  in  31  per  cent,  of 
these  there  was  actual  shortening. 

In  233  cases  adduction  was  present,  and  in  70  per  cent,  the 
limb  was  shorter  than  its  fellow.^ 

The  mechanics  of  the  distortion  as  indicative  of  the  destruc- 
tive stage  of  the  disease  will  be  made  clearer  if  it  be  compared 
to  the  deformity  caused  by  dorsal  dislocation  of  the  hip.  In  this 
displacement  the  femur,  forced  upward  and  backward  upon  the 
pelvis,  is  fixed  in  an  attitude  of  extreme  flexion,  adduction,  and 
inward  rotation.  Each  of  the  destructive  changes  of  hip  disease, 
the  enlargement  of  the  acetabulum,  the  depression  of  the  neck 
of  the  femur,  and  the  erosion  of  the  head  of  the  bone,  is  accom- 
panied by  an  elevation  of  the  femur  upon  the  pelvis  or  an  ap- 
proximation to  a  dorsal  displacement  (Fig.  219).  If  this  dis- 
placement occurs  suddenly,  as  in  certain  cases  of  acute  disease 
attended  by  effusion  and  rupture  of  the  capsule,  the  limb  imme- 
diately assumes  an  attitude  typical  of  dorsal  dislocation ;  but  in 
the  ordinary  form  of  disease  the  changes  are  very  gradual ;  the 
pelvis  and  the  femur,  being  in  most  instances  undeveloped,  more 
readily  accommodate  themselves  to  the  changed  conditions,  so 
that  the  actual  distortion  is  less  marked  than  in  a  similar  sub- 
luxation' of  traumatic  origin  in  the  adult ;  but  the  simile  will 
serve  to  illustrate  the  mechanical  causes  of  distortion,  and  why 
such  deformity  may  recur  after  correction,  even  though  the  dis- 
ease has  entirely  disappeared.  Outward  rotation  of  the  limb 
is  usually  associated  with  abduction,  and  inward  rotation  with 
adduction,  but  in  certain  instances  outward  rotation  may  be 
combined  with  adduction  and  inward  rotation  with  abduction. 
These  irregular  attitudes  are  more  often  observed  in  cases  that 
have  received  mechanical  or  operative  treatment  than  in  those 
in  which  the  disease  has  pursued  its  natural  course. 

As  has  been  stated,  the  distortions  of  the  early  stage  of  hip 
disease  are  caused  almost  entirely  by  muscular  contraction  which 
relaxes  under  the  influence  of  an  ansesthetic,  but  after  a  time  the 
attitude  is  confirmed  by  accommodative  changes  in  the  muscles 
and  fasciae,  and  by  contractions  and  adhesions  about  the  capsule. 
Thus  an  attitude  originally  a  symptom  persists  after  the  cure 
of  the  disease. 

^  Koenig,  Das  Hoeftgelenk,  Berlin,  1902. 


318 


ORTHOPEDIC  SURGEEY. 


One  may  conclude  then  that  flexion  is  practically  an  invari- 
able symptom  in  hip  disease  because  complete  extension,  the 
attitude  that  puts  most  strain  upon  the  joint,  is  first  restricted. 


Fig.  218. 


Fig.  219. 


The  final  effect  of  hip  disease  wheu 
untreated.  The  natural  cure,  witli 
flexion  and  adduction.  Compensatory 
recurvation  of  the  knee  on  the  sound 
side  is  also  shown. 


Untreated  hip  disease.  Flexion  de- 
formity to  nearly  a  right  angle  with 
the  body.  Trochanter  two  inches  above 
Nelaton's  line.  Compensatory  lor- 
dosis. 


Flexion  in  the  milder  or  in  the  earlier  class  of  cases  is  usually 
combined  with  abduction  and  outward  rotation,  the  attitude  o£ 
inactivity.  Increased  flexion,  accompanied  by  adduction  and 
inward  rotation  is  an  indication  of  a  more  acute  phase  of  the 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


319 


Fig.  220. 


disease.  If  the  attitude  is  retained  for  a  time  it  becomes  fixed 
by  accommodative  changes  in  the  tissues ;  thus  the  distortion  is 
not  unusual  in  cases  in  which 
the  damage  to  the  joint  may  be 
very  slight,  as,  for  example, 
when  it  follows  rheumatism  or 
some  form  of  infectious  arthri- 
tis. But  in  most  instances  the 
attitude  is  indicative  of  more 
advanced  disease  and  of  destruc- 
tive changes  within  the  joint. 

Changes  in  the  Contour  of  the 
Hip.— The  changes  in  contour 
are  caused  primarily  by  the  at- 
titude of  the  limb.  If,  as  is 
usual,  it  is  flexed,  abducted,  and 
rotated  outward  the  buttock  ap- 
pears  somewhat     flatter     and 

bjroader_than  its  fellow.  The 
gluteofempral  fold  is  lawar  be- 
cause of  the  tilting  dowiivvard 
of  the  pelvis  and  it  is^^shallosier 
because  of  the  flexion.  If  the 
thigh  is  adducted,  the  gluteal 
fold  is  elevated  and  shortened. 
On  the  anterior  aspect,  the  in- 
guinofemoral fold  is  deepened 
and  lengthened  by  flexion  and 
adduction  while  abduction  makes 
it  less  noticeable.  Hoffman  has 
called  attention  to  the  fact  that 
the  genitals  and  the  intergluteal 
fold  point  toward  the  adducted 
and  away  from  the  abducted 
thigh.  Adduction  makes  the 
trochanter  more  prominent,  and 
abduction  makes  it  less  promi- 
nent. 


Stage  of  apparent  shortening.  The 
left  limb  Is  adducted  35°,  making  an 
apparent  shortening  measured  from 
the  umbilicus  of  more  than  two 
inches.  In  order  to  reduce  the  ob- 
liquity of  the  pelvis,  the  adducted 
leg  must  be  crossed  over  its  fellow. 
(See  Fig.  216.)  The  apparent  short- 
ening is  compensated  by  the  flexion 
at  the  knee  on  the  sound  side.  This 
is  not  made  clear  in  the  photograph. 


To  these  primary  changes  in 
the  appearances  must  be  added  the  effect  of  atrophy  or  of  infll- 
tration  and  swelling,  due  directly  to  the  disease.  A  certain 
amount  of  swelling  indicating  effusion  into  the  joint  is  often 


320  OBTSOPEDIC  SUBGEBY. 

apparent  in  the  inguinofemoral  region,  and  infiltration  of  the 
deeper  tissues  is  sometimes  evident  on  palpation.  In  such  cases 
there  is  usually  a  certain  sensitiveness  to  deep  pressure  behind 
or  in  front  of  the  trochanter.  Palpable  abscess  is  unusual  in  the 
early  stage  of  the  disease. 

Atrophy.. — Atrophy  is  an  important  sign  of  joint  disease.  It 
is  often  appreciable  to  the  eye  and  to  the  hand,  and  it  is  always 
demonstrable  by  measurement.  It  is  an  important  symptom, 
because,  if  v^ell-marked,  it  shows  that  the  disease  must  have 
existed  for  some  time,  whatever  may  be  the  statement  of  the 
patient's  relatives. 

The  atrophy  affects  the  muscles  of  the  entire  limb,  although 
it  is  somewhat  more  marked  in  the  muscles  of  the  thigh  than  in 
the  calf.  In  the  ordinary  case  of  hip  disease  in  childhood,  when 
the  patient  is  first  brought  for  treatment,  it  averages  from  one- 
half  to  one  inch  in  the  thigh  and  somewhat  less  in  the  calf.  As 
has  been  stated  elsewhere,  atrophy  of  muscles  is  usually  accom- 
panied by  a  corresponding  atrophy  of  bone  as  well. 

The  Causes  of  Atkophy. — Admitting  that  the  secondary 
causes  of  atrophy  are  somewhat  obscure,  one  cause,  and  by  far 
the  most  important,  is  very  evident.  This  is  physiological  dis- 
use, and  thus  diminished  nutrition  of  the  limb,  which  has  be- 
come incompetent  to  carry  out  its  full  function.  Atrophy  is  a 
constant  symptom  of  simple  disuse  in  the  absence  of  disease.  If 
a  bone  has  been  broken,  atrophy  of  the  muscles  is  observed.  If 
anchylosis  of  a  joint  occurs  from  any  cause,  whether  it  be  from 
injury  or  disease,  atrophy  of  the  muscles,  whose  function  has 
been  abolished,  follows.  Even  the  atrophy  caused  by  disease  of 
the  hip-joint  is  greater  when  the  limb  has  been  fixed  in  appara- 
tus than  when  none  has  been  applied,  although  the  treatment  has 
allayed  the  pain  and  has  checked  the  progress  of  the  disease. 
This  point  is  illustrated  by  the  observations  of  Brackett,^  who 
contrasted  the  atrophy  of  hip  disease  in  two  groups  of  patients, 
in  one  of  which  motion  had  been  permitted,  while  in  the  other 
fixation,  as  complete  as  possible,  had  been  employed.  In  the 
first  group  the  average  of  atrophy  was  but  1  per  cent,  of  the 
vohime  of  the  thigh  and  0.89  per  cent,  of  that  of  the  leg,  as  con- 
trasted with  23  per  cent,  and  17  per  cent,  in  the  second  class. 

According  to  the  investigations  of  Bum,^  simple  fixation  of  a 
sound  limb  induces  more  rapid  atrophy  than  is  caused  by  dis- 
ease of  a  joint  when  function  has  been  permitted.     Nov  can  the 

^  Transactions  American  Orthopedic  Association,  vol.  iv. 
-  Zeit.  f.  chir.,  December  9,  1905. 


TUBERCULOUS  DISEASE  OF  THE  EIP-JOINT.  321 

atrophy  induced  by  simple  fixation  be  increased  by  the  induc- 
tion of  disease  in  the  fixed  joint.^ 

The  atrophy  caused  by  physiological  disuse  and  diminished 
nutrition  affects  all  the  components  of  the  limb.  The  skin  be- 
comes thinner,  the  muscles  lose  in  volume,  the  contractile  sub- 

FiG.  221. 


Early  stage  of  disease  of  the  left  hip-joint   (to  the  right  in  the  picture)    of  the 
synovial  type,  showing  irregularity   in  the  shape   of  the  acetabulum. 

stance  is  replaced  in  part  by  fat  and  by  fibrous  tissue,  and  the 
medullary  canals  of  the  bones  enlarge  at  the  expense  of  the 
cortical  substance. 

In  childhood  disuse  often  causes  a  retardation  in  growth  of 
the  entire  extremity.     This  may  be  apparent  in  the  foot  when 

^Wien.  Med.  Presse,  51,  1906. 
21 


322 


OBTHOPEDIC  SUBGEBY. 


it  is  placed  bv  the  side  of  its  fellow,  while  the  diminished 
growth  in  the  length  of  the  limb  may  be  demonstrated  by  meas- 
urement. Brackett,  in  a  series  of  cases,  found  this  shortening 
to  be  distributed  as  follows:  average  loss  of  the  femur  6.6  per 
cent,  and  of  the  tibia  5.4  per  cent,  of  the  normal  length. 

Atrophy  becomes  less  noticeable  after  function  is  resumed. 

Fig.  222. 


Advanced  disease,  showing  wandering  of  tbe  acetabulum  and  the  obliquity  of 
the  pelvis  due  to  adduction.  Actual  shortening  one  inch,  apparent  shortening 
three  inches. 


the  degree  of  final  inequality  depending  upon  the  severity  of 
the  disease,  the  duration  of  the  treatment,  and  upon  the  impair- 
ment of  function.  But  even  when  free  motion  in  the  joint  is 
retained,  a  certain  degree  of  atrophy  always  persists  and  the  loss 
in  growth  is  never  regained.     If  motion  is  completely  lost  the 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


323 


muscles  about  the  joint  lose  in  bulk  in  proportion  to  the  disuse 
of  their  normal  function;  whereas  the  bones  of  the  limb  which 
are  still  used  to  support  the  weight  retain  to  a  greater  degree 
their  normal  size  and  length.  Contrasted  with  this  atrophy 
there  is  a  relative  hypertrophy  of  the  sound  limb,  which  is 
forced  to  assume  more  than  its  share  of  work. 

Actual  Shoktenijstg. — ^Actual  shortening  of  the  limb  is  an 
effect  rather  than  a  diagnostic  symptom  of  hip  disease. 

Fig.  223. 


Illustrating  the  destructive  type  of  hip  disease.     The  limb  having  been  fixed  in 
abduction.     No  displacement  is  present. 


The  causes  of  actual  shortening  may  be  classified  as : 

1.  Disuse  of  the  limb. 

2.  The  effect  of  the  disease  upon  the  epiphyseal  cartilage  of 
the  head  of  the  femur. 

3.  The  more  general  destructive  effects  of  the  disease  that 
cause  upward  displacement  of  the  femur. 

(a)   Erosion  of  the  head. 

(&)   Erosion  of  the  acetabulum. 


324  OBTHOPEDIC  SUBGEEY. 

(c)  Depression  of  the  neck  of  the  femur. 

(d)  Dislocation. 

Disuse,  throughout  a  long  i^eriocl  of  treatment,  causes  a  cer- 
tain amount  of  shortening  of  the  entire  limb.  To  this  the 
shortening  of  the  bones  of  the  leg  and  of  the  foot  may  be  attrib- 
uted in  great  part.  If  the  epiphyseal  cartilage  uniting  the 
neck  and  the  head  of  the  femur  is  destroyed  in  whole  or  in  part 
or  if  the  disease  hastens  union  at  this  point,  a  certain  loss  of 
growth  must  follow.  This  is,  of  course,  slight  in  degree,  because 
growth  here  is  relatively  unimportant  compared  with  that  at 
the  lower  extremity  of  the  femur. 

Erosion  of  the  head  of  the  femur  and  of  the  upper  border  of 
the  acetabulum  are  usually  combined  in  those  cases  in  which  the 
shortening  is  in  part  dependent  on  upward  displacement  of  the 
trochanter  (Fig.  209).  Depression  of  the  neck  of  the  femur  to 
an  appreciable  degree  is  less  common.  Elevation  of  the  trochan- 
ter, due  to  one  or  more  of  these  causes,  a  form  of  subluxation, 
is  very  common,  particularly  so  in  those  cases  in  which  the  pro- 
tective treatment  has  been  inefficient.  Greater  displacement 
follows  fracture  of  the  weakened  neck  and  complete  absorption 
of  the  head,  and  occasionally  a  fairly  normal  femur  may  be  actu- 
ally dislocated  as  a  result  of  sudden  effusion  into  the  joint 
with  rupture  of  the  capsule — a  form  of  pathological  dislocation. 

It  may  be  stated  also  that  partial  or  complete  displacement 
forward  (anterior  subluxation)  is  not  uncommon.  In  such 
cases  there  is  marked  outward  rotation  of  the  limb  with  but 
slight  shortening,  the  head  of  the  bone  presenting  by  the  side  of 
the  anterior  inferior  spine  of  the  pelvis. 

Retardation  of  Growth. — As  has  been  stated,  all  the  com- 
ponents of  the  limb  are  affected  by  the  retardation  of  the  growth. 
Brackett's  observations  on  this  point  have  been  mentioned,  and 
the  table  on  the  following  page,  showing  the  relative  measures 
of  the  bones  in  cases  under  treatment  by  Dollinger,^  of  Buda- 
pest, presents  the  subject  in  a  convenient  form: 


^Zeits.  f.  Orth.  Chir..  1892,  Bel.  i. 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


325 


No.  of 

Age  at 
inception. 

Duration  of 
disease. 

Length  of 
femur  in  cm. 

Differ- 
ence. 

Length  of 
tibia  in  cm. 

Differ- 

case. 

Years. 

Months. 

Years 

Months. 

Dis- 
eased. 

Nor- 
mal. 

Dis- 
eased. 

Nor- 
mal. 

ence. 

1 

8 

6 

6 

28* 

28 

+i 

24 

24 

2 

3 

4 

8 

23" 

24 

1 

19 

19 

3 

2 

10 

"i 

8 

24 

24 

19.5 

19.5 

4 

5 

2 

29 

30 

"i 

23.5 

23.5 

5 

6 

2 

27 

28 

1 

23 

23 

6 

7 

2 

32 

33 

1 

27 

27 

7 

9 

2 

37 

37 

... 

30 

30 

8 

1 

4 

22 

24 

"2 

18.5 

19 

0.5 

9 

13 

4 

38 

41 

3 

34 

34 

10 

4 

"e 

5 

32 

34 

2 

27 

27 

... 

11 

2J 

6 

26 

27 

1 

21.5 

23 

1 

12 

13 

7  ■ 

38 

40 

2 

33 

33 

... 

13 

2 

8 

35 

36 

1 

28 

28 

... 

14 

6 

8 

38 

38 

31 

32 

... 

15 

11 

8 

40 

44 

4 

34 

34 

... 

16 

5 

10 

45 

46 

1 

17 

5 

11 

41 

44 

3 

31 

37 

e" 

18 

6 

14 

44 

48 

4 

36 

39.5 

3.5 

19 

2 

18 

36 

46 

10 

38 

38 

20 

2 

28 

44*  !     45 

* 

37.5  i     37.5 

A  similar  investigation  of  thirtv-three  cases  nnder  treatment 
at  the  Hospital  for  Ruptured  and  Crippled,  ISTew  York,  has  been 
made  recently  by  Taylor.  In  these  cases  the  shortening  of  the 
bones  was  found  to  be  more  generally  distributed  than  in  those 
reported  by  Dollinger,  as  is  illustrated  by  the  table  on  the  fol- 
lowing page. 

Dr.  Taylor  measured  also  ten  cases  of  unilateral  poliomye- 
litis, in  patients  of  an  average  age  of  thirteen  years,  with  an 
average  duration  of  disability  of  ten  years.  The  average  short- 
ening in  these  cases  was  one  and  three-fourths  inches,  and  in  no 
case  was  it  greater  than  two  and  one-half  inches.  It  will  be 
noted  that  the  retardation  of  growth  in  this  group  corresponds 
closely  with  that  of  the  third  group  of  cases  of  hip  disease,  in 
which  the  disability  was  of  about  the  same  duration.  Taylor 
concludes  that  the  retardation  of  growth  from  unilateral  hip' 
disease  in  childhood  is  dependent  in  great  degree  upon  the 
duration  of  the  disability  and  upon  the  corresponding  restraint 
of  function.  Similar  observations  on  fifty  cases  of  hip  disease 
have  been  recorded  by  Hibbs.^ 

Actual   Lengthening-.- — Lengthening   of   the   limb    as   the 

result  of  disease  is  occasionally  observed  during  the  active  stage 

of  the   disease,   caused,   it  may  be   inferred,   by   granulations 

within  the  acetabulum  that  press  the  femur  outward  and  down- 

^New  York  Medical  Journal,  December  16,  1899. 


326 


OETHOPEDIC  SUEGEEY. 


ward.  Actual  lengthening  of  the  femur  is  uncommon,  but  it 
does  occur,  induced,  it  may  be,  bj  stimulation  of  the  growth  of 
the  epiphysis  of  the  head;  but  the  most  extreme  instances  are 
those  in  which  the  upper  portion  of  the  shaft  of  the  femur  is 
involved,  the  lengthening  being  the  effect  of  an  irritative  hyper- 
trophy. This  is  more  commonly  the  result  of  extra-articular 
disease. 


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—  Measurements    equal.  x  Measurements    not    taken. 

Measurements  of  the  femur  from  the  apex  of  the  great  trochanter  to 
the  knee-joint.  Patella  measured  trans^■ersely.  The  cases  are  grouped 
according  to  the  duration  of  disease  and  the  averages  are  given  separately 
for  each  group. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  327 

General  Sjmaptoms  of  the  Disease. — Debility. — If  the  disease 
is  sufficiently  painful  to  cause  loss  of  sleep  and  to  affect  the  ap- 
petite, pallor  and  loss  of  flesh  and  strength  may  be  expected. 
It  must  be  borne  in  mind,  however,  that  the  patient  may  have 
been  in  poor  condition  long  before  the  local  tuberculous  disease 
was  acquired.  At  all  events  from  the  diagnostic  standpoint  at 
least,  the  local  disease  has  no  characteristic  influence  upon  the 
general  condition,  and  the  appearance  of  perfect  health  is  not 
at  all  unusual  among  patients  with  hip  disease. 

Fever.. — It  is  probable  that  a  slight  elevation  of  temperature 
might  be  detected  in  a  large  proportion  of  the  patients,  and  in 
such  cases  actual  appreciable  fever  often  follows  overexertion  of 
injury.  Fever,  as  a  symptom  of  infected  abscess  in  the  later 
course  of  the  disease,  is,  of  course,  of  importance,  but  in  the 
early  stages  of  the  disease  the  record  of  the  temperature  would 
be  of  but  little  diagnostic  value. 

History  and  Method  of  Examination. — In  considering  the 
differential  diagnosis  of  tuberculous  disease  of  the  hip-joint 
one  should  keep  its  characteristics  in  mind.  It  is  a  chronic 
disease,  in  that  the  symptoms  have  usually  persisted  for  weeks 
or  months  before  the  patient  is  brought  for  treatment.  It  is 
essentially  a  monarticular  disease,  thus  differing  from  rheu- 
matism and  similar  affections  in  which  several  joints  are  in- 
volved. It  does  not  get  well ;  thus  it  may  be  differentiated  from 
injury  and  from  the  minor  affections  that  simulate  some  of  its 
symptoms.  It  causes  a  limp.  It  is  accompanied  by  reflex 
muscular  spasm,  usually  by  a  certain  degree  of  deformity  and 
by  general  atrophy  of  the  muscles  of  the  limb. 

The  importance  of  the  inheritance  and  of  the  personal  history 
of  the  patient  has  been  mentioned  already  in  the  consideration 
of  Pott's  disease.  In  recording  the  history  in  this  as  in  all  other 
chronic  diseases  of  childhood  one  attempts  to  ascertain  the  ap- 
proximate duration  of  the  pathological  process  rather  than  the 
duration  of  the  more  acute  symptoms  for  which  the  patient  has 
been  brought  for  treatment.  One  asks,  therefore,  when  the  child 
was  last  perfectly  well,  and,  bearing  in  mind  the  remission  of 
symptoms,  one  asks  if  limp  or  pain  had  been  noticed  at  any  time 
before  the  more  acute  symptoms.  In  the  history  there  is  almost 
invariably  mention  of  a  fall,  and  one  must  ascertain  whether  the 
fall  had  any  influence  in  the  causation  of  the  symptoms,  remem- 
bering that  the  weakness  and  interference  with  function  due  to 
joint  disease  more  often  cause  falls  than  falls  cause  joint  disease. 


328  OBTHOPEDIC  SUSGEEY. 

Physical  Examination. — One  begins  the  physical  examination 
by  the  observation  of  the  general  condition  of  the  patient,  and 
notes  the  attitudes,  and  the  character  of  the  limp.  The  patient's 
clothing  is  then  entirely  removed,  that  one  may  observe  the 
contour  of  the  part  and  the  general  influence  of  the  afl^ection 
upon  the  mechanism  of  the  body.  The  patient  is  then  placed 
on  his  back  upon  a  table,  with  the  limbs  parallel  to  one  another, 
so  that  length  and  size  may  be  compared.  If  the  pelvis  is  level 
when  the  limbs  are  parallel,  there  can  be  no  persistent  abduction 
or  adduction,  for  when  the  two  anterior  superior  spines  are  on 
the  same  plane  such  distortion  is  always  evident.  If  the  lumbar 
spine  and  the  popliteal  surfaces  of  the  knees  rest  on  the  table 
simultaneously  it  shows,  too,  that  persistent  flexion  is  absent. 
One  next  tests  the  function  of  the  hip-joints,  always  beginning 
with  the  sound  side  for  the  purpose  of  comparison,  and  in  order 
that  the  patient  may  become  accustomed  to  the  manipulation 
before  the  one  suspected  of  disease  is  tested.  Disease  within 
a  joint  is  accompanied  by  muscular  spasm  that  limits  motion  in 
every  direction,  thus  difi^ering  from  other  affections  outside  the 
joint  that  may  limit  its  motion  in  one  or  more  but  not  in  all 
directions. 

One  compares  the  flexion,  abduction,  adduction,  and  roiation 
of  the  limbs  while  the  child  lies  upon  its  back ;  it  is  then  turned 
upon  its  face  to  test  for  extension  by  holding  the  pelvis  flat 
upon  the  table  with  one  hand  while  the  thigh  is  gently  elevated 
with  the  other  (Fig.  16).  The  normal  range  of  extension  in 
childhood  is  about  twenty  degrees  backward  from  the  line  of  the 
body,  and  limitation  of  this  range  is  the  earliest  indication  of 
the  deformity  of  hip  disease.  It  may  precede  the  restriction  of 
the  extremes  of  motion  in  other  directions,  although  this  is 
unusual,  and  if  this  motion  is  unrestricted  disease  of  the  joint 
may  be,  practically  speaking,  excluded.  The  character  of  the 
reflex  spasm  that  limits  motion  and  the  indications  of  discomfort 
when  the  limit  has  been  reached  have  been  described. 

Measurements. — The  measurements  of  the  limbs  are  then 
made.  One  first  ascertains  the  actual  length  of  the  limbs  by 
measuring  from  the  anterior  superior  spines  of  the  pelvis  to  the 
extremities  of  the  internal  malleoli,  actual  shortening  being  of 
course  absent  in  the  early  stage  of  the  disease.  The  second 
measurement  is  from  the  umbilicus  to  show  the  amount  of  ap- 
parent shortening  or  lengthening  that  mnj  be  present  if  the  limb 
is  distorted.     The  actual  length  of  the  limbs,  as  measured  from 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  329 

the  anterior  superior  spines,  is  but  slightly  affected  by  tilting  of 
the  pelvis,  but  as  the  umbilicus  is  in  the  middle  line  of  the  body 
above  the  pelvis  measurement  from  this  point  simply  shows  the 
actual  distance  to  the  malleoli.  Persistent  adduction  causes  com- 
pensatory obliquity  of  the  pelvis ;  consequently  the  malleolus 
on  the  affected  side  is  drawn  upward  or  nearer  to  the  umbilicus, 
while  the  other  is  carried  downward  to  a  corresponding  distance 
(Fig.  220).  If,  then,  the  measurements  from  the  umbilicus  to 
the  malleoli  do  not  correspond  relatively  with  those  from  the 
anterior  superior  spines,  when  the  limbs  are  parallel  and  in  the 
median  line,  it  shows  distortion ;  adduction,  if  the  limb  is 
relatively  shorter,  abduction,  if  it  is  relatively  longer  than  is 
shown  by  the  measurement  from  the  anterior  superior  spine.  It 
has  been  stated  that  the  measurement  from  the  anterior  superior 
spine  is  not  greatly  changed  by  distortion.  It  is,  however,  short- 
ened by  abduction,  and  it  is  correspondingly  lengthened  by 
adduction.  This  is  exj)lained  as  follows:  When  the  limb  is  in 
the  line  of  the  body  the  trochanter  is  below  the  anterior  superior 
spine  from  which  the  measurement  is  made.  Abduction  of  the 
limb  raises  the  trochanter  toward  the  plane  of  the  anterior 
superior  spine,  and  consequently  lessens  the  distance  from  this 
point  to  the  extremity  of  the  limb.  Adduction,  on  the  contrary, 
lowers  the  trochanter  and  increases  the  distance  between  these 
two  points.  Ordinarily  the  variation  from  this  source  does  not 
exceed  half  an  inch.  But  if  the  distortion  is  considerable  the 
error  must  be  corrected  by  placing  the  sound  limb  in  the  same 
attitude  in  which  its  fellow  is  fixed.  The  measurements  will 
then  be  relatively,  though  not  absolutely,  accurate.  Flexion  of 
one  thigh  causes  a  tilting  forward  of  the  pelvis  that  lessens  the 
distance  between  the  anterior  superior  spine  and  the  malleolus 
on  both  sides,  although  not  to  an  equal  degree.  It  is  customary, 
therefore,  if  the  flexion  is  considerable,  to  raise  the  unaffected 
limb  to  the  line  of  its  fellow  in  making  the  comparative  measure- 
ments, stating  in  the  record  that  the  limbs'  have  been  measured 
at  the  angle  of  the  deformity  and  are  therefore  shortened. 

In  this  connection  it  may  be  noted  that  a  slight  difference  in 
the  length  of  the  limbs  is  not  uncommon  (78  per  cent,  of  128 
observations),  usually  in  favor  of  the  right  side,  the  variation 
being  one-fourth  to  one-half  an  inch.^ 

Method  of  Estimating  the  Degree  of  DiSTOETioisr  of  the 
Limb. — As  has  been  stated,  when  the  pelvis  is  level,  distortion 
^  Bristow,  Annals  of  Surgery,  July,   1909. 


130 


OFiTHOPEDIC  SUEGEEY. 


of  the  limb  is  apparent,  and  the  degree  of  distortion  can  be 
measured  by  the  goniometer  (Fig.  216)  ;  but  it  may  be  more 
easily  ascertained  by  "  Lovett's  table."^  This  method  is  de- 
scribed by  its  author  as  follows : 

Table  foe  EsTiMATi]srcT  the  Degree  of  Lateral  Distortion, 
Distance  between  Anterior  Superior  Spines  in  Inches. 


^K 


12 


4K 


3° 

6 
10 
13 


4' 
7 
11 
17  14 
21  |18  16 
25  22  119 
30  ,26  23 
35  i30  ,26 
34  130 


5K 


40 


10 
14  13 

17  !l5 
20  1 18 
23  l21  19 
26  24  21 


39 


27  24 

29  27 

32  29 

36  |32 

40  35 

...  38 

...  42 


6>^ 

7 

7>^ 

8 

8K 

9 

2° 

2° 

2° 

2° 

2° 

2° 

4 

4 

4 

4 

4 

4 

7 

6 

6 

5 

5 

5 

9 

8 

7 

7 

7 

6 

11 

10 

9 

9 

8 

8 

13 

12 

12 

11 

10 

10 

15 

14 

13 

13 

12 

11 

18 

16 

15 

14 

14 

13 

20 

19 

17 

16 

15 

14 

22 

21 

19 

18 

17 

16 

25 

23 

21 

20 

19 

18 

27 

25 

23 

22 

21 

19 

'30 

27 

26 

25 

22 

21 

33 

30 

28 

26 

24 

23 

35 

32 

30 

28 

26 

25 

38 

35 

32 

30 

28 

26 

9%     10   11   12   13 


1^ 
3 

4 
6 
7 
9 

10 
13 
13 
14 

17  16 

18  '18 
20  19 


1° 

2 
3 
4 
6 

7 
8 
9 


10 

11  10 

12  |11 

13  12 

14  12 

15  14 

19  17  16 

20  18  17 

21  19  18 


"  To  measure  by  this  method  the  patient  is  made  to  lie  straight 
with  the  legs  parallel.  •  Real  shortening  is  measured  with  the 
ordinary  tape  measure,  and  apparent  shortening  is  obtained  in 
the  same  way.  It  may  be  repeated  that  real  or  bony  shortening 
is  measured  from  the  anterior  superior  iliac  spines  to  each  mal- 
leolus, and  that  practical  shortening  is  found  by  a  measurement 
taken  from  the  umbilicus  to  each  malleolus.  The  difference  in 
inches  between  the  two  kinds  of  shortening  is  seen  at  a  glance. 
The  only  additional  measurement  necessary  is  the  distance  be- 
tween the  anterior  superior  spines,  which  is  taken  with  the  tape. 
Turning  now  to  the  table :  if  the  line  which  represents  the 
amount  of  difference  in  inches  between  the  real  and  apparent 
shortening  is  followed  until  it  intersects  the  line  which  repre- 
sents the  pelvic  breadth,  the  angle  of  deformity  will  be  found  in 
degrees  where  they  meet.  //  the  practical  shortening  .is  greater 
than  the  real  shortening,  the  diseased  leg  is  adductedj  if  less 
than  real  shortening,  it  is  abducted.  Take  an  example:  Length 
(from  anterior  superior  spine)  of  right  leg,  23 ;  left  leg,  22^ ; 
length  (from  umbilicus)  of  right  leg,  25 ;  left  leg,  23 ;  real 
shortening,  i/>  inch;  apparent  shortening,  2  inches;  difference 
between  real  and  practical  shortening,  11^  inches ;  pelvic  meas- 
urement, 1  inches.     If  we  follow  the  line  for  fl/o  inches  until 

^  E.  W.  Lovett,  Boston  Medical  and  Surgical  Journal,  March  8,  1888. 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  331 

it  intersects  the  line  for  pelvic  breadth  of  7  inches,  we  find  12 
degrees  to  be  the  angular  deformity,  as  the  practical  shortening 
is  greater  than  the  real,  it  is  12  degrees  of  adduction  of  the  left 
leg.  If  apparent  lengthening  is  present  its  amount  should  be 
added  to  the  amount  of  actual  shortening." 

If  flexion  is  present  the  degree  may.  be  ascertained  by  raising 
the  flexed  limb  until  the  lumbar  spine  touches  the  table,  when 
the  angle  formed  by  the  thigh  with  the  body  may  be  measured 
with  the  goniometer  (Fig.  215)  or  its  degree  may  be  ascer- 
tained by  Kingsley's  table  (p.  332). 

"  The  patient  lies  upon  a  table  flat  on  his  back  and  the 
surgeon  flexes  the  diseased  leg,  raising  it  by  the  foot  until  the 

'  Fig.  224. 


A  C 

Kingsley's  method  of  estimating  flexion.  ' 

lumbar  vertebrae  touch  the  table,  showing  that  the  pelvis  is  in 
the  correct  position.  The  leg  is  then  held  for  a  minute  at  that 
angle,  the  knee  being  extended,  while  the  surgeon  measures  off 
two  feet  on  the  outside  of  the  leg  with  a  tape  measure,  one  end 
of  which  is  held  on  the  table,  so  that  the  tape  measure  follows 
the  line  of  the  leg  (A-B).  From  this  point  on  the  leg  (B) 
where  the  two  feet  reach  by  the  tape  measure  one  measures  per- 
pendicularly to  the  table  (B-C),  and  the  number  of  inches  in 
the  line  B-C  can  be  read  as  degrees  of  flexion  of  the  thigh  by 
consulting  Table  II.  For  instance,  if  the  distance  between  the 
point  on  the  leg  and  the  table  is  12^  inches  it  represents  31 
degrees  of  flexion  deformity  of  the  thigh. 


332 


ORTHOPEDIC  SUSGEBY. 


Table  for  Estimating  the  Degree  of  Flexion.^ 


0.5  inches. 

1° 

6.5  inches. 

16° 

12.5  inches. 

31° 

18.5  inches. 

50° 

1.0   " 

2 

7.0   " 

17 

13.0   " 

33 

19.0   " 

52 

1.5   " 

3 

7.5   " 

19 

13.5   " 

34 

19.")   " 

54 

2.0   " 

4 

8.0   " 

20 

14.0   " 

36 

20.0   " 

56 

2.5   " 

6 

8.5   " 

21 

14.5   " 

37 

20.5   " 

58 

3.0   " 

7 

9.0   " 

22 

15.0   " 

39 

21.0   " 

60 

3.5   " 

9 

9.5   " 

24 

15.5   " 

40 

21.5   " 

63 

4.0   " 

10 

10.0   " 

25 

16.0   " 

42 

22.0   " 

67 

4.5   " 

11 

10.5   " 

27 

16.5   " 

43 

22.5   " 

70 

5  0   " 

12 

11.0   " 

28 

17.0   " 

45 

23.0   " 

75 

5.5   " 

14 

11.5   " 

29 

17.5   " 

47 

23.5   " 

80 

6.0   " 

15 

12.0   " 

30 

18.0   " 

48 

24.0   " 

90 

"  If  the  leg  is  so  short  that  it  is  impracticable  to  measure  off 
twentv-four  inches  one  can  measure  twelve  inches ;  ascertain 
from  here  the  distance  to  the  surface  on  which  the  patient  is 
lying  in  a  perpendicular  line  in  the  same  way,  then  doubling 
this  distance  and  looking  in  the  table  as  before  the  amount  of 
flexion  in  found." 

Ateophy. — The  circumference  of  the  thighs,  the  knees,  and 
the  calves  is  then  measured  af  corresponding  points  to  test  for 
atrophy  or  for  other  irregularities  that  may  require  explanation. 
The  atrophy  of  joint  disease  affects  the  entire  limb,  and  it  is  an 
unfailing  symptom  except  in  the  earliest  stage  of  the  disease. 
It  might  be  concealed  in  the  thigh  by  a  deep  abscess,  but  it  would 
still  appear  in  the  calf. 

Local  Signs  of  Disease. — The  hip-joint  is  so  concealed  by  the 
overlying  tissues  that  the  local  sensitiveness  and  swelling  which 
usually  accompany  similar  disease  at  the  knee  and  ankle  are 
often  absent.  Firm  pressure  before  or  behind  the  trochanter, 
or  over  the  head  of  the  femur  usually  causes  some  discomfort, 
however.  In  many  instances  a  j^eculiar  resistance  of  the  deeper 
parts,  caused  by  infiltration  of  the  tissues  that  cover  the  joint, 
is  evident  on  palpation ;  and  swelling  about  the  joint  and  thigh, 
caused  by  effusion  or  by  deep  abscess,  is  not  unusual  when 
patients  are  first  brought  for  treatment.  Sensitiveness  of  the 
skin  and  local  elevation  of  the  temperature  may  be  present  if 
the  disease  is  acute,  particularly  if  an  abscess  is  on  the  point  of 
breaking  through  the  skin. 

Diagnosis. — The  diagnosis  of  tuberculous  disease  of  the  hip, 
except,  perhaps,  in  the  stage  of  inception  is  not  difficult,  and 
errors  are  due  rather  to  a  neglect  of  a  systematic  examina- 
tion than  to  any  particular  obscurity  that  the  ordinary  case 
may  offer. 

^  G.  L.  Kingsley,  Boston  Medical  and  Surgical  Journal,  July  5,  1888. 


TUBERCULOUS  DISEASE  OF  TEE  HIP-JOINT.  333 

Local  Irritation. — Strains  of  the  muscles  of  the  thigh,  enlarged 
glands  in  the  groin,  irritation  or  disease  of  the  genitals  may, 
in  infancy  or  early  childhood,  cause  persistent  flexion  of  the 
thigh  and  pain  on  motion.  Simple  muscular  strains  quickly 
recover,  while  the  inflamed  glands  and  other  causes  of  local 
irritation  are  usually  apparent  on  inspection. 

"  Growing  Pains," — So-called  growing  pain  is  probably  due 
in  many  instances  to  strain  of  the  muscles  or  to  injury  about  the 
hip. 

Local  Injury. — It  would  appear  that  injury,  often  of  a  trivial 
character,  may  cause  congestion  in  the  neighborhood  of  the 
epiphyseal  cartilage  of  the  head  of  the  femur  and  that  injury  of 
this  character  in  delicate  children  may  be  a  predisposing  cause 
of  tuberculous  disease.  Such  a  sensitive  condition  causes  a 
limp,  j)ain,  or  discomfort  on  overuse  and  restriction  of  motion. 
These  symptoms  may  last  a  few  days  or  a  few  weeks ;  they  may 
disappear  and  recur  from  time  to  time,  and  they  can  only  be 
distinguished  from  those  of  incipient  disease  by  continued  ob- 
servation.    (See  also  Fracture  of  the  E^eck  of  the  Femur.) 

Synovitis.. — In  certain  cases  of  injury  synovial  effusion  may 
be  present,  although  this  is  unusual. 

In  the  cases  in  which  the  functional  disturbance  is  caused  by 
local  irritation  or  by  slight  strain  the  symptoms  are  of  sudden 
onset  and  are  evidently  of  trivial  importance,  but  if  there  is 
any  doubt  as  to  the  diagnosis  the  hip  should  be  bandaged  and 
the  patient  should  remain  in  bed  or  at  rest  until  the  complete 
subsidence  of  the  symptoms  or  their  persistence  makes  the  diag- 
nosis clear. 

Anterior  Poliomyelitis. — Occasionally  anterior  poliomyelitis 
may  be  accomj)anied  by  pain  on  motion  in  the  affected  limb 
before  jDaralysis  is  apparent,  but  in  a  few  days  at  most  the  diag- 
nosis is  evident. 

Eheumatism. — "  Rheumatism,"  a  term  popularly  used  to  in- 
clude all  forms  of  subacute  arthritis  induced  by  infection,  or 
by  defective  metabolism — "  toxic  arthritis  "  is  usually  of  sudden 
onset.  It  is  almost  always  migratory  in  character  and  it  is 
accompanied  by  fever.  If  it  were  confined  to  a  single  joint,  as 
is  sometimes  the  case  in  young  children,  and  if  the  history  were 
obscure,  the  diagnosis  might  be  uncertain  for  a  time.  In  such 
cases  appropriate  remedies  should  be  employed  with  the  local 
treatment. 

Scurvy. — This  is  also  an  affection  whose  symptoms  are  gen- 


334  OBTHOPEDIC  SURGEBY. 

eral  in  character.  It  is,  therefore,  more  likely  to  be  confounded 
with  rheumatism  than  with  a  local  disease.  In  rare  instances 
one  joint  only  appears  to  be  involved,  but  this  is,  as  a  rule  the 
knee  rather  than  the  hip.  Pain  on  motion  of  the  limbs,  in  an 
infant  artificially  fed,  always  suggests  scurvy. 

Infectious  Arthritis  and  Epiphysitis. — Mild  forms  of  infectious 
arthritis  may  follow  scarlatina,  diphtheria,  pneumonia,  and,  in 
a  more  severe  and  destructive  form,  typhoid  fever.  As  a  rule, 
however,  several  joints  are  involved,  and,  although  the  affection 
might  be  mistaken  for  rheumatism,  it  could  hardly  be  con- 
founded with  local  tuberculous  disease. 

Infectious  arthritis  or  epiphysitis  of  the  hip-joint  is  not  un- 
common in  early  infancy.  It  is  of  sudden  onset,  accompanied 
by  high  fever  and  by  constitutional  disturbance.  These  symp- 
toms, together  with  the  local  heat  and  swelling,  caused  by  the 
rapid  formation  of  pus,  show  the  character  of  the  affection  and 
indicate  the  necessity  for  prompt  surgical  intervention. 

Gonorrhoeal  arthritis  is  a  form  of  joint  infection  that  in  adult 
age  may  resemble  somewhat  the  subacute  form  of  tuberculous 
disease.  As  a  rule,  however,  it  is  of  sudden  onset  and  is  evi- 
dently associated  with  the  local  disease. 

Extra- articular  Disease. — Disease  in  the  neighborhood  of  the 
joint,  as  of  the  trochanter  or  of  the  tuberosity  of  the  ischium, 
may  cause  a  limp  and  pain ;  in  most  instances  the  local  sensi- 
tiveness and  local  swelling  indicate  the  seat  of  the  disease,  while 
motion  of  the  joint  is  limited  only  in  the  directions  that  cause 
tension  on  the  sensitive  parts. 

Arthritis  Deformans  of  the  Hip. — This  affection  when  confined 
to  the  hip-joint  may  be  mistaken  for  tuberculous  disease,  and  at 
times  the  diagnosis  may  be  obscure.  It  is,  however,  essentially 
a  disease  of  adult  life,  and  it  is  in  most  instances  accompanied 
by  other  evidences  of  a  general  disease. 

Atrophic  Polyarthritis.. — This  affection  in  childhood  may  begin 
in  a  single  joint.  The  pain  may  be  severe,  and  there  may 
be  muscular  spasm  and  distortion  of  the  limb.  The  diagnosis 
is  usually  made  clear  by  the  successive  involvement  of  other 
joints. 

Pott's  Disease. — Disease  of  the  lumbar  region  of  the  spine  be- 
fore the  stage  of  deformity,  when  the  pain  is  referred  to  the 
lower  extremities,  and  in  which  unilateral  psoas  contraction 
causes  a  limp,  is  often  mistaken  for  hip  disease,  although  the 
distinction  between  them  is  very  clear.    Psoas  contraction  limits 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  335 

extension  only ;  all  the  other  movements  of  the  limb  are  unre- 
strained. The  muscular  spasm,  of  which  the  psoas  contraction 
is  a  part,  is  a  spasm  of  the  muscles  of  the  spine  about  the  seat 
of  disease,  as  is  evident  on  examination.  Other  causes  of  psoas 
contraction  have  been  mentioned  in  the  consideration  of  Pott's 
disease.  In  exceptional  cases  active  disease  of  the  lower  region 
of  the  spine  in  young  children  may  set  up  spasm  of  the  muscles 
about  the  hip,  and  vice  versa,  so  that  it  may  be  impossible  to 
decide  at  the  first  examination  whether  the  irritation  is  in  the 
hip  or  in  the  spine  or  in  both. 

Sacroiliac  Disease. — Disease  of  the  sacroiliac  junction  is  very 
uncommon  in  childhood.  The  symptoms  and  the  attitude  re- 
semble sciatica  rather  than  hip  disease.  There  is  local  pain  at 
the  seat  of  disease  upon  lateral  pressure  on  the  pelvis,  and  if  the 
pelvis  be  fixed  the  motion  at  the  hip-joint  will  be  found  to  be 
practically  free  and  painless. 

Pelvic  Disease. — Localized  disease  of  one  of  the  pelvic  bones 
may  cause  discomfort  and  a  limp.  The  cause  of  the  symptoms 
is  usually  explained  by  the  appearance  of  an  abscess. 

Disease  of  the  Bursse  about  the  Joint. — Inflammation  of  the 
bursse  about  the  hip  may  cause  local  swelling  and  sensitiveness, 
a  limp  and  limitation  of  motion  in  certain  directions,  but  the 
characteristic  muscular  spasm  of  hip  disease  is  absent.  Ilio- 
psoas bursitis  forms  a  fluctuating  swelling  in  Scarpa's  space, 
gluteal  bursitis  a  localized  swelling  of  the  buttock. 

Coxa  Vara. — Depression  of  the  neck  of  the  femur  is  a  simple 
deformity.  It  causes  a  limp  and  more  "orless  discomfort,  but 
the  character  of  the  deformity,  shown  by  the  actual  shortening 
and  by  the  elevation  and  prominence  of  the  trochanter  dis- 
tinguishes it  from  hip  disease,  in  which  these  are  late  symp- 
toms. In  coxa  vara  there  is  unequal  limitation  of  motion,  ab- 
duction, flexion,  and  inward  rotation  being  somewhat  restricted, 
while  extension  and  adduction,  the  first  movements  limited  in 
hip  disease,  are  as  a  rule  not. 

Fracture  of  the  Neck  of  the  Femur  in  Childhood  or  Traumatic' 
Coxa  Vara. — Fracture  of  the  neck  of  the  femur  in  childhood  is 
often  of  what  may  be  termed  the  green-stick  variety,  a  depres- 
sion of  the  neck  of  the  femur  without  actual  separation  of  the 
fragments ;  and  in  many  instances  the  patients  are  able  to  walk 
about  within  a  short  time  after  the  accident.  In  such  cases  the 
limp  and  'discomfort,  attended  during  the  stage  of  repair  by  a 
certain  degree  of  muscular  spasm,  are  often  mistaken  for  the 


336  ORTHOPEDIC  SUBGEBY. 

symptoms  of  disease.  The  historv  of  the  accident  followed  by 
immediate  disability,  the  shortening  and  the  elevation  of  the 
trochanter  are  nsnally  sufficient  to  exclude  disease.  In  doubt- 
ful cases  the  X-ray  may  be  required  to  establish  the  diagnosis. 

Epiphyseal  Fracture. — Epiphyseal  fracture  is  more  common  in 
adolescence.  It  may  be  induced  by  slight  injury  and  if  the  dis- 
placement is  not  complete  the  patient  is  often  able  to  use  the 
limb.  A  more  detailed  description  of  injuries  of  this  class  may 
be  found  elsewhere. 

Congenital  Dislocation  of  the  Hip. — Congenital  dislocation  of 
the  hip  causes  a  limp,  but  it  is  a  limp  that  has  existed  since  the 
child  began  to  walk  and  that  is  unaccompanied  by  the  symptoms 
of  disease.  The  nature  of  the  disability  should  be  apparent  on 
examination. 

Hysterical  Joint. — In  hysterical  subjects  a  limp,  apparent 
pain,  and  distortion  of  the  limb,  often  following  slight  injury, 
may  simulate  disease.  Hysteria  is  very  uncommon  at  the 
period  of  life  in  which  tuberculous  disease  is  most  frequent. 
Patients  of  this  class  usually  present  other  symptoms  of  hys- 
teria ;  the  characteristic  signs  of  disease,  muscular  spasm  and 
atrojDhy,  are  absent,  while  the  apparent  discomfort  and  the 
voluntary  distortion  are  quite  out  of  proportion  to  the  physical 
evidences  of  injury  or  disease. 

The  X-ray  in  Diagnosis. — Roentgen  pictures  are  of  far  more 
value  in  demonstrating  deformity  than  in  establishing  early 
diagnosis  of  disease,  especially  of  the  hip  in  early  childhood, 
when  so  large  a  part  of  the  extremity  of  the  femur  is  car- 
tilaginous ;  the  only  constant  indications  of  disease  being 
atrophy  of  the  shaft  of  the  femur  and  a  blurred  outline,  "  foggi- 
ness,"  of  the  parts  actually  involved.  The  pictures  are  of  value, 
however,  in  showing  the  destructive  effect  of  the  disease  on  the 
head  of  the  femur  or  acetabulum,  and  thus  giving  one  a  clearer 
conception  of  the  actual  condition  of  the  joint  than  would  be 
possible  otherwise  (Fig.  223).  In  older  subjects  it  may  be 
possible  to  demonstrate  the  presence  of  disease  in  the  interior 
of  the  bone  by  this  means,  but  in  any  event  Roentgen  pictures 
are  of  value  only  when  interpreted  by  knowledge  of  the  physical 
signs. 

Method  of  Recording  a  Case. — The  record  should  contain  the 
general  history  of  the  patient  together  with  an  account  of  the 
more  important  symptoms,  and  of  the  treatment  that  may  have 
been  employed.     The  physical  examination  should  include  the 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  337 

weight  and  height  for  comparison  with  the  normal  standard, 
and  as  a  basis  on  which  to  judge  the  future  progress  of  the  case. 
Then  follows  a  brief  description  of  the  gait  and  attitude,  of  the 
character  of  the  distortion,  if  it  be  present,  and  of  the  changes 
from  the  normal  contour.  If  restriction  of  motion  is  present, 
its  causes  are  stated  if  possible ;  whether,  for  example,  it  is  due 
to  simple  muscular  spasm  or  in  part  to  adhesions  and  con- 
tractions. 

The  presence  or  absence  of  heat  and  swelling,  of  abscesses, 
sinuses,  and  the  like  is  indicated.  If  there  is  actual  shortening 
of  the  limb  its  causes  and  distribution  should  be  stated ;  whether 
it  is  the  result  of  simple  retardation  of  growth  or  of  elevation  of 
the  trochanter,  as  may  be  ascertained  by  IS'elaton's  line  and  by 
Bryant's  triangle. 

If  the  elevation  is  due  in  great  part  to  the  enlargement  of  the 
acetabulum,  while  the  upper  extremity  of  the  femur  remains 
fairly  normal  in  shape,  the  projection  of  the  trochanter  is  more 
noticeable,  and  the  distortion  of  the  limb  in  adduction  is  greater, 
than  when  the  elevation  is  the  result  of  destruction  of  the  head 
of  the  bone.  In  this  class  of  cases  Roentgen  pictures  are  of 
service  in  showing  the  actual  condition  of  the  joint  (Fig.  210). 

A  condensed  account  of  the  more  important  points  in  the 
physical  examination  may  be  presented  by  the  formula  used  at 
the  Hospital  for  Ruptured  and  Crippled,  as  follows:  R.A. — 
R.U.— R.T.— R.K.— R.C.— A.G.E.— A.G.F.— A.S.P.— L.A.— 
L.U.— L.T.— L.K.— L.C. 

"  A  "  indicates  the  distance  from  the  anterior  superior  spines 
to  the  internal  malleoli. 

"  U,"  from  the  umbilicus  to  the  same  points. 

"  T,"  "  K,"  and  "  C,"  the  circumferences  of  the  limb  at  the 
thighs,  knees,  and  calves. 

"  A.G.E."  indicates  the  angle  of  greatest  extension. 

"A.G.F.,"  the  angle  of  greatest  flexion.  Thus  the  restric- 
tion of  the  range  of  anteroposterior  motion  at  the  hip  is  shown 
by  these  measurements. 

"A.S.P."  is  the  transverse  diameter  of  the  pelvis  between 
the  anterior  superior  spines,  the  measurement  required  in 
Lovett's  table  for  ascertaining  the  degree  of  lateral  distortion. 

If,  for  example,  the  record  reads : 

-A.S.P.  7 


R.A.  18*— R.U.  20  - 
L.A.  18i— L.U.  211- 

—E.T.  11  - 

-L.T.  lOi- 

R.K.Sf     E.G.  7|     A.G.E.  150- 
-L.K.  81— L.C.  71— A.G.F.  90 

22 

338  OETEOPEDIC  SUBGEBY. 

it  Avoiild  show  at  a  glance  that  there  was  no  real  shortening,  that 
the  limb  was  abducted  because  of  the  one  and  a  quarter  inches 
of  apparent  lengthening,  according  to  the  table,  the  equivalent 
of  10  degrees  of  abduction.  It  would  show  that  there  was  per- 
manent flexion  of  30  degrees  and  a  range  of  motion  between 
the  limits  of  flexion  and  extension  of  60  degrees,  as  compared 
with  the  normal  of  about  130  degrees. 

The  following  details  of  the  one  thousand  cases  of  hip  disease 
investigated  for  me  by  Ashley  are  of  interest  as  illustrating  the 
character  of  the  cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled : 

The  Duration  of  Disease  when  Treatment  was  Begun. 

Three  months  or  less 396       Four  years 21 

Three  to  six  months 170       Five  years   17 

One  year 124       From  five  to  ten  years 35 

Two  years    75       From  ten  to  forty  years.  .  .      16 

Three  years   29       Not  stated   37 

1000 

The  Degree  of  Deformity  Present  on  First  Examination. 

No   deformity    130  55  degrees  of  flexion 10 

5  degrees  of  flexion 44  60  degrees  of  flexion 26 

10  degrees  of  flexion 89  65  degrees  of  flexion 8 

15  degrees  of  flexion 69  70  degrees  of  flexion 22 

20  degrees  of  flexion 118  75  degrees  of  flexion 2 

25  degrees  of  flexion 32  80  degrees  of  flexion 11 

30  degrees  of  flexion 135  85  degrees  of  flexion 1 

35  degrees  of  flexion 56  90  degrees  of  flexion 12 

40  degrees  of  flexion 70  More  than  90 1 

45  degrees  of  flexion 41  Not  stated 55 


50  degrees  of  flexion 68 


1000 


Restriction  of  Motion  at  First  Examination. 

Normal   motion    30 

A  range  of  motion  through  105  degrees 14 

A  range  of  motion  through     90  degrees 65 

A  range  of  motion  through     75  degrees 49 

A  range  of  motion  through     60  degrees 95 

A  range  of  motion  through     45  degrees 67 

A  range  of  motion  through     30  degrees 112 

A  range  of  motion  through     15  degrees 95 

A  range  of  motion  through       5  degrees 157 

No   motion    147 

Not   stated    169 

1000 
Attitude  of  the  Limb  at  First  Examination. 

Flexion  to  a  greater  or  less  degree 814 

No  flexion   130 

Not   stated    56 

1000 
Other  Distortions   Eecorded. 

Abduction    254 

Adduction     167 

External   rotation    166 

Internal    rotation    58 


TUBEBCULOUS  DISEASE  OF  TEE  HIP-JOINT.  339 

Actual   Shortening  when  Treatment  was  Begun. 

14  inch   129  21^    inches 5 

1/0  inch 143  21/2    inches 5 

%  inch 22  2%   inches.. 2 

1  inch 51  3        inches 2 

114  inch 9  314    inches 2 

1%  inch   16  31^    inches 2 

1%  inch   6  91/2    inches _i 

2  inch   21  416 

Shortening  absent  or  not  stated  in 584 

Abscess  not  present  in 105 

^--Treatment. — The  principles  that  should  govern  the  treatment 
of  a  disease  are  best  indicated  by  the  study  of  cases  that  have 
received  no  treatment,  and  that  present,  therefore,  the  natural 
history  of  the  affection. 

A  characteristic  case  of  tuberculous  disease  of  the  hip-joint 
begins  insidiously.  It  causes  a  slight  limp  and  at  times  dis- 
comfort and  pain.  At  first  there  is  slight  flexion  of  the  limb, 
usually  combined  with  abduction,  the  instinctive  assumption 
of  the  attitude  of  rest.  As  the  disease  progresses  the  limb  be- 
comes less  capable  of  performing  its  proper  function ;  the  range 
of  motion  becomes  more  and  more  restricted,  and  the  attitude 
changes  to  one  of  increased  flexion  and  adduction,  the  attitude 
in  which  the  limb  is  best  protected  from  injury  because  it  is 
least  capable  of  function.  Pain  is  more  constant,  abscess  is 
often  present,  and  the  constitutional  effects  of  a  depressing  dis- 
ease may  be  apparent.  This  progression  of  symptoms  and  atti- 
tudes is  so  fairly  constant  that  hip  disease  was  formerly  divided 
into  stages  corresponding  to  these  early  and  later  manifes- 
tations of  its  effects.  When  the  limb  has  reached  the  position, 
of  greatest  protection,  when  motion  which  at  first  was  limited 
only  by  the  involuntary  spasm  of  the  muscles  that  are  now 
atrophied,  is  restricted  by  adhesions  and  contractions,  pain 
often  ceases,  the  general  health  improves,  and  effective  repair 
begins.  During  the  progressive  stage  erosion  of  the  opposing 
surfaces  of  the  joint  has  advanced,  always  more  rapidly  at  the 
points  of  mutual  pressure  and  friction,  the  upper  and  inner 
surface  of  the  head  of  the  femur  and  the  upper  margin  of  the 
acetabulum,  and  here  the  disease  remains  active  while  repair 
progresses  at  the  points  which  have  been  relieved  from  irrita- 
tion. Thus  in  many  instances  the  upper  margin  of  the  aceta- 
bulum is  destroyed  and  a  subluxation  of  the  femur  takes  place 
(Fig.  210),  a  displacement  favored  by  the  attitude  of  flexion 
and  adduction,  and  induced  by  muscular  spasm  and  by  pressure 


340  OETHOPEDIC  SUEGEEY. 

upon  the  limb.  In  some  instances  there  is  complete  displace- 
ment, and  when  the  diseased  parts  are  thus  separated  from  one 
another  hj  this  form  of  pathological  dislocation  relief  of  symp- 
toms and  practical  recovery  may  quickly  follow,  although 
sinuses  leading  to  areas  of  local  disease  or  to  fragments  of 
necrosed  bone  may  persist  for  many  years. 

I^ature's  cure  of  hip  disease  implies  recovery  with  a  shortened 
and  distorted  limb,  a  final  result  which  is  common  enough  even 
when  treatment  has  been  employed  to  explain  the  popular  con- 
ception of  what  hip  disease  entails  (Fig.  219). 

As  has  been  stated,  it  was  customary  in  former  years,  when 
treatment  was  neglected  or  was  less  efficient  than  at  the  present 
time,  to  speak  of  a  first,  second,  and  third  stage  of  hip  disease, 
corresponding  to  the  character  of  the  deformity,  but  early  or  later 
stage  as  used  by  the  writer  refers  to  the  inception  and  progres- 
sion of  the  local  pathological  process,  not  to  the  distortion  of  the 
limb. 

There  are  cases  of  hip  disease  in  which  the  primary  focus 
in  the  head  of  the  bone  is  so  limited  in  extent  that  perfect  func- 
tional cure  may  result  under  any  form  of  treatment,  or  non- 
treatment  even.  And  there  are  others  in  which  the  disease  is 
of  such  a  destructive  character  that  the  result  must  be  disastrous 
in  spite  of  treatment.  But  there  can  be  no  doubt  that  by  early 
diagnosis  and  by  efiicient  protection  prolonged  suffering  may  be 
prevented,  that  useful  function  may  be  preserved,  which  would 
otherwise  have  been  lost. 

The  object  of  treatment  is  to  prevent  the  symptoms  and  the 
effects  of  the  disease  that  have  been  outlined  as  characteristic 
of  the  untreated  cases.  To  relieve  the  pain  that  depresses  the 
vitality  of  the  patient.  To  relieve  the  muscular  spasm  that 
induces  distortion  of  the  limb,  and  that  stimulates  the  activity 
of  the  destructive  process  by  increasing  the  pressure  and  fric- 
tion of  the  diseased  surfaces  of  the  opposing  bones.  To  correct 
and  to  prevent  deformity  and  to  prevent,  as  far  as  may  be  by 
lessening  the  pressure  and  by  restraining  motion,  the  upward 
displacement  of  the  femur  that  causes  irremediable  distortion. 

There  are  cases  in  which  radical  removal  of  the  diseased  parts 
may  be  indicated,  and  there  are  times  when  acute  symptoms 
may  require  absolute  rest  of  the  patient.  But  in  the  manage- 
ment of  a  chronic  tuberculous  disease,  throughout  the  period  of 
years  that  must  elapse  before  cure  is  accomplished,  the  primary 
requirements  of  the  treatment  that  have  been  indicated  must  be 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  341 

met,  as  far  as  may  be,  by  appliances  that  permit  exercise  in  the 
open  air. 

Mechanical  Treatment. — Effective  treatment  of  a  diseased  joint 
must  assure  rest  and  protection.  If  the  disease  is  in  the 
earliest  stage  and  confined  to  the  interior  of  the  bone,  rest 
offers  the  most  favorable  condition  for  repair  and  for  preserva- 
tion of  the  joint.  If  the  disease  is  further  advanced,  it  affords 
an  opportunity  for  nature  to  check  its  progress  and  to  preserve, 
it  may  be,  a  part  of  the  joint  from  invasion.  If  the  joint  is 
already  involved,  rest  offers  the  best  opportunity  for  repair  by 
preventing  friction  that  stimulates  the  progress  of  the  disease 
and  increases  its  destructive  effects.  Whatever  checks  or  retards 
the  progress  of  the  disease  relieves  its  symptoms  and  thus  pre- 
serves the  vital  resistance,  both  local  and  general,  upon  which 
the  cure  of  the  disease  ultimately  depends.  Complete  rest  of  a 
diseased  joint  of  the  lower  extremity  necessitates  splinting, 
stilting  and  traction. 

Splinting  naturally  signifies  the  fixation  that  may  be  at- 
tained by  the  application  of  a  splint,  extending  a  sufficient  dis- 
tance on  either  side  of  the  part  to  be  fixed. 

Stilting — the  elevation  of  the  foot  from  the  ground  so  that 
jar  and  pressure  on  the  diseased  articulation  may  be  removed. 

Traction — a  sufficient  force  exerted  upon  the  limb  to  over- 
come and  to  control  the  spasmodic  action  of  the  muscles. 

The  knee-joint,  the  junction  of  two  levers  of  similar  size  and 
function,  may  be  easily  fixed  by  apparatus.  But  the  hip-joint 
is  a  ball  and  socket  joint  which  permits  motion  in  many  direc- 
tions, and,  being  the  junction  of  the  trunk  and  the  limb,  two 
segments  of  different  size  and  function,  it  is  especially  difiicult 
to  control.  For  this  reason  as  much  as  any  other,  perhaps  the 
mechanical  treatment  of  hip  disease  has  been  the  subject  of 
controversy  for  many  years.  And  even  at  the  present  time  one 
can  not  describe  it  adequately  without  contrasting  the  methods 
of  treatment  that  are  in  common  use. 

Such  an  exposition  should  begin  naturally  with  a  description 
of  what  has  long  been  known  as  the  American  treatment,  in 
which  traction  has  always  occupied  the  most  important  place. 

The  Traction  Hip  Splint. — The  traction  hip  splint  consists  of  a 
pelvic  band  and  an  upright.  The  pelvic  band  is  made  of  sheet 
steel  about  an  eighth  of  an  inch  in  thickness  and  one  and  one- 
eighth  inches  in  width,  sufficiently  strong  to  support  the  weight 
of  the  body  without  yielding,  bent  into  a  U-shape  to  conform  to 


342 


OBTHOPEDIC  SUBGEBY. 


the  pelvis^  but  wide  enough  to  cause  no  anteroposterior  pressure. 
As  Taylor  puts  it,  there  should  be  room  enough  for  the  pelvis  to 
move  freely  in  it.  This  band  embraces  about  three-quarters  of 
the  pelvis  at  a  point  just  above  the  trochanter.  It  is  covered 
vs^ith  leather,  and  is  provided  with  a  strap  to  complete  the  cir- 
cumference. Upon  the  pelvic  band  four  buckles  are  placed  for 
the  attachment  of  the  perineal  bands.     The  two  buckles  on  the 


Fig.  225. 


Fig.  226. 


Fig.  227. 


The   traction    hip    splint,    with    overlapping    upright    and    windlass,    used    at    the 
Boston    Children's   Hospital.      (Bradford   and   Lovett.) 


front  band  are  placed  directly  above  the  attachments  of  the  ad- 
ductor muscles,  on  either  side  of  the  genitals.  Behind,  the 
buckles  are  placed  much  farther  apart,  somewhat  to  the  outer 
side  of  each  ischial  tuberosity,  upon  which  in  great  part,  the 
weight  of  the  body  is  to  be  supported.  The  pelvic  band  is  bolted 
firmly  to  the  upright  at  a  slight  inclination,  corresponding  to 
the  inclination  of  the  j)elvis.  The  upright  extends  from  the  top 
of  the  trochanter  to  two  or  more  inches  below  the  sole  of  the 
foot.  It  may  be  made  in  one  piece  or  in  two  sections  over- 
lapped and  attached  to  one  another  by  screws,  to  allow  for  ad- 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  343 

justment  (Fig,  226).  It  is  turned  inward  at  a  right  angle 
below  the  foot  and  is  shod  with  leather  or  rubber.  The  foot- 
piece  may  be  provided  with  a  windlass  (Fig.  226),  or  the  trac- 
tion may  be  made  by  simple  straps  attached  on  either  side  (Fig. 
231).  At  about  the  middle  of  the  upright  is  placed  a  support 
of  light  steel,  which  is  provided  with  a  broad  leather  strap  for 
the  purpose  of  fixing  the  thigh  to  the  brace  and  supporting  the 
knee.  In  some  braces  a  second  similar  support  is  placed  at  the 
upper  part  of  the  stem ;  in  others  the  knee  is  supported  only  by 
a  broad  leather  pad  which  covers  its  inner  surface  and  is 
attached  to  a  cross-piece  on  the  upright  by  straps,  as  in  the 
Taylor  brace.  In  the  Taylor  brace,  which  has  served  as  a  model 
for  all  similar  appliances,  the  upright  is  a  steel  tube  into  which 
slides  a  rod,  supporting  the  foot  part  of  the  brace,  the  two  parts 
being  joined  with  a  rack-and-pinion  attachment  and  lock,  so 
that  the  brace  may  be  lengthened  or  shortened  by  means  of  a 
key  (Fig.  230). 

Traction  Plasters. — Traction  upon  the  limb  is  made  by  ad- 
hesive plaster,  preferably  that  known  as  moleskin  (yellow) 
plaster,  which  is  far  less  irritating  to  the  skin  than  rubber 
plaster. 

These  plasters  should  be  cut  to  correspond  to  the  lateral 
aspect  of  the  thigh  and  leg,  thus :  wide  above  and  narrow  be- 
low, reaching  fropi  the  trochanter  on  the  outer,  and  from  the 
pubes  on  the  innei*  side,  to  the  malleoli  (Fig.  240).  The  lower 
ends  are  reinforced  by  a  second  layer  of  plaster  and  to  them 
buckles  are  attached.  The  plasters  are  then  applied  to  the  limb 
and  are  held  in  place  by  a  bandage  which  is  smoothly  applied 
and  then  sewed,  to  prevent  disarrangement.  The  object  of  the 
bandage  is  primarily  to  assure  the  adhesion  of  the  plaster  and 
secondarily  to  keep  it  clean.  It  can  be  replaced  by  a  properly 
fitted  covering  of  stockinette  or  by  a  stocking  leg. 

Another  method  of  applying  the  plaster,  designed  to  obtain 
a  better  hold  upon  the  limb,  is  that  devised  by  Taylor,  and  de- 
scribed by  him  as  follows:  "The  first  important  object  is  to 
seize  the  leg  in  such  a  manner  as  to  exert  against  it  an  unyield- 
ing force.  This  should  be  done  in  such  a  manner  as  will  not 
interfere  with  the  circulation,  nor  injure  the  knee,  by  unequal 
strain  either  below  or  above  it.  In  other  words,  the  whole  leg 
should  be  grasped  in  such  a  manner  that  the  knee  will  be  sup- 
ported. It  may  be  done  as  follows :  A  strip  of  adhesive  plaster, 
long  enough  to  reach  from  the  waist  to  the  foot,  and  from  three 


344 


ORTHOPEDIC  SURGERY. 


to  five  inches  wide  at  the  upper  and  about  one-third  that  width 
at  the  lower  end,  is  taken  and  cut  into  five  tails,  as  shown  in  the 
accompanying  illustration  (Fig.  228).  A  piece  from  four  to 
six  inches  long  is  cut  from  the  centre  tail  and  added  to  the  lower 
end  to  strengthen  it ;  and,  if  the  patient  be  strong,  one  or  two 


Fig.  228. 


Fig.  229. 


C.  p.  Taylor's  method  of  applying  adhesive  plaster. 

more  pieces  are  laid  on  the  same  place,  where  a  buckle  is  at- 
tached. Two  similar  straps  are  prepared,  one  for  the  inside 
and  one  for  the  outside  of  the  leg,  and  laid  against  the  lateral 
aspects  of  the  leg,  the  ends  with  the  buckles  beginning  about 
two  inches  above  the  internal  and  external  malleoli,  and  the 
centre  tails  reaching  the  entire  length  of  the  leg  and  thigh,  to 
the  j)erineum  inside  and  the  trochanter  on  the  outside.  The 
lower  strips  or  tails  are  then  wound  spirally  around  the  leg  to 
the  pelvis  and  afterward  the  other  two  pairs  of  tails,  which  are 
cut  dovrai  to  just  above  the  knee,  are  also  wound  about  the  thigh 


TUBEBCULOUS  DISEASE  OF  THE  EIP-JOINT. 


345 


Fig.  230. 


in  the  same  manner.  When  completed  the  thigh  is  involved  in 
a  network  of  strips  of  adhesive  plaster,  which  act  equally  and 
without  pressure  on  the  whole  surface.  The  leg  has  about  one- 
fourth  of  the  attachments,  and  the  thigh  three-fourths,  which  is 
found  to  be  the  right  proportion  to  protect  the  knee  equally  from 
compression  or  strain.  A  few 
turns  of  the  roller  bandage  are 
then  made  around  the  ankle  just 
under  the  lower  ends  of  the  straps, 
which  serves  as  a  protection  to  the 
flesh  under  the  buckles,  and  then  it 
is  continued  over  the  straps  on  the 
whole  leg.  Thus  prepared,  the 
patient  is  ready  for  the  splint " 
(Fig.  229). 

At  the  Boston  Children's  Hos- 
pital the  lower  ends  of  the  adhesive 
straps  terminate  in  tapes  that  ex- 
tend below  the  foot  for  attachment 
to  the  windlass,  which  is  used  with 
the  cheaper  form  of  brace. 

Perineal  Bands. — Perineal  bands 
are  made  by  covering  a  firm,  wide, 
unyielding  band  of  webbing  with 
several  folds  of  blanket  or  similar 
material  and  then  binding  it 
smoothly  with  canton  flannel. 
These  are  made  in  different 
lengths  and  sizes,  as  may  be  re- 
quired. 

The  "High  Shoe."— The  best 
and  lightest  material  for  raising 
the  shoe  worn  on  the  sound  foot  to 
correspond  with  the  brace  is  cork, 
and  the  ordinary  thickness  is  two  and  a  half  inches.  A  good 
and  cheap  substitute  may  be  made  of  light  wood  provided  with 
a  leather  sole,  and  in  certain  cases  a  patten  of  metal  may  be 
used. 

The  Application  of  the  Traction  Hip  Splint. — The  traction  brace 
is  applied  in  the  following  manner: 

The  patient  lying  upon  his  back,  the  pelvic  band  is  first 
adjusted  and  is  strapped  about  the  body.  The  perineal  sup- 
ports are  then  drawn  firmly  into  place  so  that  pressure  on  the 


The  original  traction  hip  brace 
provided  with  an  abduction  screw 
and  a  strap  to  regulate  the  in- 
clination of  the  pelvic  band  on 
the  upright. 


346 


OBTHOPEDIC  SUBGEBT. 


upright  does  not  move  the  pelvic  band  from  its  proper  position, 
just  above  the  trochanter.  The  brace  is  then  pushed  upward 
against  the  resistance  of  the  perineal  bands,  while  the  limb  is  at 
the  same  time  drawn  downward  and  is  fixed  hj  attaching  the 
straps  to  the  buckles  at  the  ends  of  the  adhesive  plasters.  If 
the  brace  is  provided  with  a  windlass  or  ratchet,  further  trac- 
tion is  applied  to  the  point  of  tolerance  bv  means  of  the  key, 


c 


The  Judson  brace.     This  has  but  one  perineal  band,  and  the  upright  is  bolted 
firmly  to  the  pelvic  band. 

care  being  taken  in  adjusting  the  brace  that  it  does  not  project 
so  far  below  the  foot  as  to  more  than  equal  the  extra  length 
provided  by  the  high  shoe  on  the  sound  side.  The  knee  band  is 
then  adjusted  and  in  many  instances  a  strap  is  placed  about  the 
ankle  and  the  brace  to  assure  greater  security.  The  shoe  is  then 
put  on,  the  leg  clothing  is  drawn  over  the  brace,  and  the  patient 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  347 

is  allowed  to  stand.  If  in  walking  the  patient  is  inclined  to 
tilt  the  foot  downward  and  to  bear  the  weight  on  the  toe,  a  strap 
is  attached  to  the  middle  of  the  foot-piece  and  fastened  to  a 
buckle  on  the  heel  of  the  shoe  with  sufficient  tension  to  hold  the 
foot  in  the  horizontal  position. 

By  means  of  this  brace  the  weight  is  borne  entirely  upon  the 
perineal  bands;  thus  the  joint  is  relieved  from  pressure  and 
from  jar.  The  perineal  bands  should  be  accurately  adjusted 
to  pass  upward  in  front,  parallel  to  one  another  on  either  side 
of  the  genitals,  in  order  to  avoid  pressure  on  the  inner  borders 
of  the  thighs;  while  behind  they  turn  diagonally  outward  in 
order  to  pass  over  the  tuberosities,  which  are  best  adapted  for 
weight  bearing. 

In  the  original  Taylor  hip  brace  the  pelvic  band  is  bolted  to 
the  upright  in  a  manner  to  allow  anteroposterior  motion,  and 
the  inclination  of  the  pelvic  band  is  regulated  by  a  strap  at- 
tached to  the  upright  for  better  adjustment  (Fig.  230),  when 
the  limb  is  flexed  to  a  marked  degree.  This  brace  has  been 
modified  by  Taylor  by  shortening  and  changing  the  shape  of 
the  pelvic  band  for  the  use  of  but  one  perineal  support  (Fig. 
269)  ;  and  a  similar  form  of  brace  is  used  by  Judson.  The 
shortened  pelvic  band  lessens  the  restraint  of  the  brace  upon  the 
motion  of  the  limb,  and  seems  to  offer  little  compensating 
advantage. 

Bradford  uses  a  modification  of  the  Thomas  knee  splint  with 
an  attachment  to  prevent  adduction.  This  provides  a  solid 
support  for  the  perineum  and  better  fixation  of  the  joint. 

Before  the  traction  brace  is  used  in  ambulatory  treatment, 
distortion  of  the  limb,  if  it  be  present,  should  be  reduced ;  or  if 
the  disease  is  particularly  acute,  preliminary  rest  in  bed  until 
the  subsidence  of  the  symptoms  is  advisable. 

The  Reduction  of  Deformity  by  Means  of  the  Traction  Brace 

The  patient  lies  in  bed  upon  a  firm  mattress ;  the  distorted  limb 
is  then  raised  to  slightly  more  than  a  sufficient  angle  to  relax 
the  contracted  muscles  and  to  straighten  the  lumbar  lordosis ; 
it  is  then  abducted  or  adducted  if  necessary  until  the  level  of 
the  pelvis  is  restored.  The  pelvic  band  is  made  to  conform  to 
this  greater  relative  inclination  of  the  pelvis  by  lengthening  the 
posterior  strap ;  the  brace  is  then  applied,  the  limb  being  held 
in  the  attitude  of  deformity  by  a  sling  or  support  (Fig.  232), 
and  as  much  traction  as  the  patient  can  tolerate  is  exerted  by 
lengthening  the  upright.      The  direct  traction  exerted  by  the 


348  OBTHOPEDIC  SUBGEBY. 

brace  may  be  reinforced  bj  means  of  a  cord  running  over  a 
pulley  at  the  foot  of  the  bed,  in  the  line  of  the  brace,  to  which  a 
weight  of  ten  or  more  i30unds  (Fig.  239)  is  attached.  Thus  the 
pressure  of  the  perineal  bands  is  somewhat  lessened.  Efficient 
traction  will  quickly  reduce  recent  deformity  caused  by  muscu- 
lar contraction,  and  as  this  is  lessened  the  position  of  the  limb 
is  correspondingly  changed  until  it  lies  extended  and  parallel 

Fig.  232. 


The  reduction  of  flexion  by  means  of  the  traction  hip  splint.      (C.   F.  Taylor.) 

with  its  fellow.  If  adduction  is  combined  with  flexion  the 
perineal  band  on  the  side  opposite  to  the  disease  is  tightened 
from  time  to  time,  or  a  direct  push  against  the  opposite  adduc- 
tor region  may  be  exerted  by  means  of  a  bar  attached  to  the  brace 
opposite  the  knee  (Fig.  368),  In  ordinary  cases  the  deformity 
may  be  reduced  by  this  means  in  from  two  to  six  weeks. 

If,  as  in  most  instances,  the  brace  is  not  at  immediate  com- 
mand the  deformity  may  be  reduced  by  direct  traction. 

Reduction  of  Deformity  by  the  Weight  and  Pulley. — The  traction 
plasters  are  applied  to  the  limb  in  the  manner  already  described, 
and  the  patient  is  placed  on  his  back  on  a  narrow,  firm  mattress. 
The  limb  is  raised  until  the  lumbar  vertebrae  rest  upon  the  bed 
and  it  is  then  moved  to  one  or  the  other  side,  if  lateral  distortion 
is  present,  until  the  level  of  the  pelvis  is  restored.  In  this  posi- 
tion the  limb  is  supported  on  a  pillow,  or  better,  on  the  adjustable 
triangle  used  with  the  traction  hip  splint  (Fig.  232).  A  pulley 
is  then  attached  to  the  foot  of  the  bed  in  a  prolongation  of  the 
line  of  the  flexed  limb.  The  wheel  may  be  screwed  to  the  top 
of  a  narrow  board,  which  may  be  raised  or  lowered  on  the  foot 
of  the  bed  as  required.  To  the  buckles  on  the  plaster  traction 
straps,  a  stirrup  carrying  the  cord  is  attached.  This  stirrup  is 
simply  a  spreader  of  narrow  thin  wood,  slightly  wider  than  the 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


349 


foot,  provided  at  either  end  with  straps  or  tapes,  its  purpose 
being  to  prevent  direct  pressure  on  the  malleoli  (Fig.  238).  By 
means  of  a  weight  suspended  at  the  foot  of  the  bed  traction  is 
made  upon  the  limb  to  the  extent  that  the  comfort  of  the  patient 
will  permit.    As  in  Buck's  system  of  traction,  the  foot  of  the  bed 


Fig.  233. 


Weight  extension  acting  as  leverage  in  tiip  disease.     P,  pulley ;  W,  weight ; 
F,  fulcrum.      (Howard  Marsh.) 

may  be  raised  to  increase  the  friction  of  the  body  and  thus  to 
counteract  the  traction  force,  but  in  the  treatment  of  children 
this  is  inefficient  and  countertraction  must  be  provided.  A  simple 
method  is  to  attach  two  perineal  bands,  as  described  in  connec- 
tion with  the  traction  brace,  to  strong  tapes  that  pass  above  and 
below  the  patient's  body,  to  be  fixed  to  the  head  of  the  bed  at  a 
suitable  distance  from  one  another ;  thus  the  pelvis  is  supported 
by  prolonged  perineal  bands. 

In  order  to  assure  eflicient  and  constant  traction  the  patient 
must  be  prevented  from  sitting  up.  For  this  purpose  a  swathe 
about  the  body  or  shoulder  straj)s  may  be  applied  and  attached 
to  the  bed. 

A  convenient  appliance  is  that  of  Marsh :  "  This  consists  of 
a  piece  of  webbing,  passing  across  the  front  of  the  chest  and 

Fig.  234. 


Posture  of  the  limb  in  hip  disease  in  which  traction  should  be  applied  in  order 
to  avoid  leverage.     P,  pulley ;  W,  weight ;  F,  fulcrum. — Marsh. 

ending  in  two  loops,  through  which  the  two  arms  are  passed, 
and  through  which  is  threaded  another  piece  of  stout  webbing 
which  runs  transversely  across  the  surface  of  the  bed  under  the 
child's  shoulders,  and  is  fastened  at  its  two  ends  to  the  sides  of 
the  bedstead.    When  this  is  in  action  the  patient's  shoulders  are 


350 


OBTHOPEDIC  SUSGEEY. 


kept  flat  on  the  bed,  so  that  he  can  neither  sit  up  nor  turn  on  his 
side.  This  chest  band  does  not  cause  the  slightest  discomfort. 
It  is  not,  of  course,  fixed  tightly,  and  when  the  child  finds  that  he 
cannot  sit  up  he  makes  no  further  attempt  to  do  so ;  and  as  he 
lies  flat  the  band  is  loose." 

It  is  often  of  advantage,  particularly  if  the  disease  is  active, 
to  use  some  form  of  apj)aratus  to  -Qs.  the  patient  more  thoroughly. 
JMarsh  uses  a  long  lateral  splint  of  thin  board  reaching  from  the 
axilla  to  a  crossbar  below  the  sole  of  the  foot.  To  this  the  pa- 
tient's body  and  sound  limb  are  bandaged  (Fig.  235). 

Fig.  235. 


Traction    in    hip    disease.      Marsli's    method    of    fixing    the    patient    in    iDed    with 
shoulder  straps  and  a  long  T-splint  on  the  sound  side.    (Howard  Marsh.) 

For  the  same  purpose- a  plaster  spica  bandage  or  a  Thomas 
splint  may  be  applied  on  the  sound  side,  but  a  more  convenient 
appliance  is  the  frame  of  gas-pipe  covered  with  canvas  that  has 
been  described  in  the  chapter  on  Pott's  disease.  Upon  this 
frame  the  patient  can  be  fixed,  the  limb  being  elevated  by  a  sup- 
port attached  to  the  frame  or  independent  of  it  (Figs.  236  and 
237).  It  is  perhaps  needless  to  suggest  that  the  bedclothes  must 
be  held  from  the  elevated  limb ;  in  fact,  that  the  patient  must 
for  a  time  be  enclosed  in  a  tent  of  bedclothes  if  the  deformity  is 
extreme.  At  first  the  traction  weight  must  not  be  great,  but  as 
the  perineum  becomes  accustomed  to  pressure  as  much  weight 
as  can  be  tolerated  is  used,  from  ten  to  twenty  pounds  being  the 
average.  This  may  be  reduced  at  night  and  increased  during  the 
day.  Great  care  must  be  taken  to  prevent  painful  pressure  on 
the  perineum  by  careful  adjustment  and  frequent  inspection  of 
the  perineal  bands. 

If  the  frame  is  used  it  may  be  provided  with  a  windlass  at 


TVBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


351 


the  bottom  for  traction  and  with  an  arched  band  of  metal  across 
the  pelvis  for  the  attachment  of  the  perineal  bands,  which  behind 
are  fastened  to  the  side  bars  at  a  higher  level.     Thus  the  frame 


Fig.  236. 


Traction  by  means  of  weight  and  pulley.      (R.  T.  Taylor.) 
Fig.  237. 


Method  of  fixing  the  patient  to  the  Bradford  frame  for  traction  in  hip  disease. 

(R.   T.   Taylor.) 

may  be  made  an  independent  recumbent  splint  on  which  the 
patient  may  be  moved  about.  If,  however,  one  desires  to  exert 
traction  to  the  point  of  distraction,  the  weight  and  pulley  arrange- 


352 


OBTHOPEDIC  SUEGEBY. 
Fig.  238. 


Lateral  and  longitudinal  traction  in  hip  disease.      (Page.) 


ment  is  more  satisfactory ;  in  this  case  the  limb  should  be  placed 
in  an  attitude  of  slight  flexion  and  abduction,  so  that  the  femur 
may  be  drawn  more  directly  from  the  acetabulum. 

Lateral  Traction. — Thus  far  longitudinal  traction  has  been  con- 
sidered, but  lateral  traction  or  traction  in  the  line  of  the  neck  of 
the  femur  deserves  some  consideration. 

Mr.  Thomas,  who  condemned  all  forms  of  traction  as  deceptive 
and  irrational,  and  especially  longitudinal  traction,  speaks  thus 
of  lateral  traction :  "  For  surely  if  relief  from  pressure  be  re- 
quired, the  only  direction  in  which  this  is  possible  is  clearly  in 
the  axis  of  the  neck  of  the  femur.  Any  method  of  extension  in  . 
the  axis  of  the  body  merely  transfers  the  pressure  from  the  upper 
part  of  the  acetabulum  to  the  lower  quarter."^  This  contention 
is  purely  theoretical,  as  there  is  no  evidence  to  show  that  in- 
jurious pressure  is  exerted  upon  this  part  of  the  acetabulum. 
On  the  contrary,  the  specimens  from  subjects  who  have  been 
treated  by  longitudinal  traction  in  recumbency  and  by  means  of 
the  traction  hip  splint  almost  invariably  show  the  effect  of 
pressure  upon  the  upper  part  of  the  head  of  the  femur  and  upon 
the  upper  adjoining  margin  of  the  acetabulum.  Moreover,  the 
neck  of  the  femur  is  in  childhood  so  short  and  is  set  upon  the 
shaft  at  so  great  an  angle  that  longitudinal  traction,  if  the  limb 
is  slightly  abducted,  is,  practically  speaking,  in  the  line  of  the 
neck ;  so  that  even  from  the  theoretical  standpoint  the  question 
of  injurious  pressure  could  only  arise  in  the  treatment  of  adults. 
The  advantage  of  lateral  traction  in  the  treatment  of  hip  disease 

^  Loc.  cit.,  p.  10. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  353 

was  urged  by  Phelps^  as  early  as  1889,  and  it  has  been  applied 
as  a  routine  practice  in  ambulatory  treatment  by  Blaiichard,^ 
of  Chicago,  since  1872. 

The  effect  of  lateral  traction  in  recumbency  has  been  carefully 
investigated  by  C.  G.  Page.^  His  conclusions  are  that  lateral 
traction  alone. is  of  no  benefit,  but  if  applied,  together  with  longi- 
tudinal traction,  it  gives  great  relief  in  certain  acute  cases.  The 
longitudinal  traction  should  be  twice  as  great  as  the  lateral,  ten 
and  five  j)ounds  being  the  average  weights  employed  in  his  ex- 
periments.    The  method  is  shown  in  the  illustration  (Fig.  238). 

The  brace  should  be  worn  day  and  night.  The  perineal  bands 
may  be  loosened  at  times  to  permit  cleansing  the  skin  with 
alcohol  and  for  powdering,  in  order  that  the  skin  may  be  kept 
dry ;  but  at  such  times,  if  the  disease  be  acute,  manual  traction 
should  be  made  until  the  brace  has  been  readjusted.  The  ad- 
hesive plasters,  if  of  moleskin,  may  often  remain  in  position  for 
three  months  or  longer.  When  they  are  removed  the  limb  is 
gently,  bathed  with  alcohol.     Excoriations  are  unusual  unless 

Fig.  239. 


A  method  of  reducing  flexion  in  hip  disease.  The  brace  is  adjusted  to  the 
angle  of  deformity,  and  in  addition  to  the  direct  traction  of  the  apparatus 
weights  are  attached  to  the  brace  itself.  In  the  illustration  counter-traction, 
by  means   of  perineal   bands   attached  to   the  head   of  the   bed,   is   shown. 

rubber  plaster  is  used.  If  the  skin  is  abraded  the  part  should 
be  powdered  with  boracic  acid  and  protected  from  the  plaster 
by  a  layer  of  gauze. 

The  Relative  Efficiency  of  the  Traction  Hip  Splint. — In  analyzing 
the  action  of  this  brace  it  is  evident  at  once  that  it  is  thoroughly 
effective  as  a  stilt.     It  is  effective  as  a  traction  aj)pliance,  in  the 

'New  York  Medical  Record,  May  4,  1889. 
-  Transactions  American  Orthopedic  Association,  vol.  vii. 
^  C.  G.  Page,  Boston  Medical  and  Surgical  Journal,  September  13,  1894. 
23 


354  OSTHOFEDIC  SUSGEBY. 

sense  of  relieving  mnscular  tension,  in  direct  proportion  to  the 
care  that  is  exercised  in  its  adjnstment.  Traction  by  this  ap- 
pliance may  be  made  constant  and  effective,  even  to  the  point  of 
practical  fixation  while  the  patient  is  in  bed,  or  when  crutches 
are  nsed,  in  ambulatory  treatment.  But  when  the  aj^paratus 
is  used  in  locomotion  the  traction  straps  alternately  relax  and 
tighten  as  the  weight  of  the  body  falls  upon  and  leaves  the  brace 
in  walking.  ^Yhen  the  brace  is  off  the  ground  the  joint  is  sub- 
jected to  the  traction  that  the  brace  exerts,  plus  its  weight,  as  con- 
trasted with  cessation  of  traction  and  the  relief  from  the  weight 
when  the  brace  supports  the  body  at  the  alternate  step.  Thus 
the  critics  of  the  brace  assert  that  it  exercises  a  pumping  action 
of  the  joint.  As  a  matter  of  fact,  the  observation  of  patients 
under  treatment  by  this  method  will  show  that  little  actual  trac- 
tion is  exerted  in  the  ordinary  cases ;  that  the  so-called  traction 
really  serves,  principally  for  the  adjustment  of  the  brace,  which 
by  its  weight  exercises  a  certain  intermittent  traction  during 
locomotion.  The  hold  of  the  encircling  band  upon  the  pelvis 
assures  a  considerable  restriction  of  motion ;  but  whatever  splint- 
ing action  it  may  have  depends  upon  the  degree  of  traction, 
which  is  never  effective  enough,  however,  to  prevent  a  certain 
amount  of  motion;  according  to  the  experiments  of  Lovett,  a 
range  of  at  least  35  degrees  even  when  the  brace  is  properly 
adjusted.^ 

The  traction  hip  splint  was  not  intended  to  be  a  fixation  or 
splinting  appliance.  On  the  contrary,  Davis,  its  inventor; 
Taylor,  who  changed  it  into  a  practicable  form,  and  Sayre,  who 
further  modified  it,  each  believed  that  motion,  except  when  the 
joint  was  fixed  by  muscular  spasm,  was  desirable  and  that  the 
traction  peinnitted  it  without  friction. 

Motion  without  friction  in  this  sense  would  seem  to  imply 
actual  separation  of  the  opposed  bones,  or  distraction  as  distinct 
from  traction.  That  actual  distraction  is  possible  at  the  hip- 
joint  both  in  health  and  disease  is  proved  by  the  experiments  of 
Brackett-  and  by  those  of  Bradford  and  Lovett.  These  experi- 
ments show  that  a  traction  force  from  ten  to  twenty  pounds  is 
required  to  cause  one-eighth  to  one-quarter  of  an  inch  of  actual 
lengthening  of  the  limb,  even  in  childhood  although  if  the 
muscles  are  atrophied  and  the  joint  disorganized  by  disease  a 
much  less  weight  will  separate  the  joint  surfaces  as  may  be 

^R.  W.  Lovett,  New  York  Medical  Journal,  August  8,  1891. 
=  Brackett,  Transactions  American  Orthopedic  Association,  vol.  ii.     Brad- 
ford and  Lovett,  New  York  Medical  Journal,  August  4,  1894. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


355 


Fig.  240. 


demonstrated  by  X-ray  pictures.  Under  ordinary  conditions, 
however,  it  is,  to  say  the  least,  unlikely  that  the  feeble  and  inter- 
mittent traction  exerted  by  a  hip  splint,  when  used  as  an  ambu- 
latory support,  can  be  sufficient  to  separate  the  bones  from  one 
another  or  even  to  relieve  the 
muscular  spasm  that  causes 
deformity. 

At  the  present  time-  the 
theory  that  motion  in  a  joint 
of  which  the  component  bones 
are  actually  diseased  is  of 
benefit,  or  even  that  it  is 
harmless,  has  few  supporters 
even  among  those  who  use 
the  traction  brace  exclusively. 
On  the  contrary,  the  motion 
that  cannot  be  prevented  is 
excused  because  it  is  believed 
that  no  more  effective  protec- 
tion can  be  attained  by  any 
method  of  ambulatory  treat- 
ment. 

In  all  acute  cases  a  period 
of  rest  in  bed  with  traction  to 
the  point  of  actual  distrac- 
tion is  advised.  When  am- 
bulation is  resumed  the  braced 
limb  is  made  pendent  by 
means  of  the  high  shoe  and 
crutches,  so  that  uninter- 
rupted traction  may  still  be 
exerted,  and  the  brace  is  only 
used  as  a  supporting  appli- 
ance when  the  symptoms  in- 
dicate that  the  disease  is  quiescent. 

In  hospital  practice,  the  decisive  test  of  efficiency,  the  original 
hip  brace,  has  been  in  great  degree  discarded  as  ineffective  in 
relieving  the  symptoms  and  in  preventing  deformity. 

In  its  place  the  long  traction  brace  in  some  form  is  now  used 
as  providing  better  fixation. 

This  is  illustrated  in  Fig.  240.  To  the  pelvic  band  of  the 
traction  brace  a  bar  is  attached  which  extends  in  the  axillary 
line  to  about  the  middle  of  the  scapula  where  it  supports  a  chest 


The  long,  inexpensive  brace,  witli  solid 
upright,  showing  the  perineal  bands  and 
the  adhesive  plaster,  as  used  in  hospital 
practice. 


356 


OBTHOPEDIC  SUBGEEY. 


band  of  thin  metal  covering  about  three-fourths  of  the  thorax, 
the  circumference  as  at  the  pelvis  being  completed  bj  a  strap. 
The  brace  should  be  constructed  so  as  to  hold  the  limb  in  about 
15°  of  abduction.  If  it  is  i3roperlj  adjusted,  it  assures  prac- 
tical fixation  of  the  joint. 

The  efficiency  of  the  apparatus  may  be  still  further  increased 
bj  replacing  the  perineal  bands  with  a  metallic  ring.  This  ring, 
which  fits  the  upper  extremity  of  thigh  closely,  is  attached  to 
the  upright  at  an  inclination  corresponding  to  the  line  of  the 
groin  (Fig.  242).     (The  Thomas  ring  is  described  fully  in  con- 

FiG.  241. 


The  long  hip  splint  applied. 


nection  with  his  knee  splint.)  It  is  a  better  support  because  it 
prevents  anteroposterior  motion  within  the  pelvic  band,  which 
the  perineal  straps  permit.  The  ring  may  be  used  as  the  only 
support  or  it  may  be  combined  with  a  perineal  band  on  the 
opposite  side.  This  is  of  advantage  if  there  is  a  tendency  toward 
adduction. 

The  apparatus  is  most  satisfactory  when  the  hollow  ujiright  of 
the  Taylor  brace  is  used.  This  is  light  and  strong,  and  is  pro- 
vided with  an  arrangement  for  effective  traction,  but  in  hospital 
practice  the  upright  is  made  of  solid  metal,  and  the  traction  is 
made  by  simple  straps.  The  metallic  ring,  besides  providing 
better  fixation,  is  a  firm  support  that  cannot  be  removed  by  the 
patient.  It  is,  of  course,  more  difficult  of  adjustment,  and  it  is 
not  suited  to  the  treatment  of  young  children  because  of  the  diffi- 
culty in  keeping  it  clean  and  dry. 

The  Thomas  ring  was  first  applied  to  a  hip  splint  by  Phelps 
(Fig.  244).  He  urged  the  advantages  of  fixation  and  traction, 
and  his  brace,  of  which  that  last  described  is  simply  a  slight 
modification,  is  provided  with  an  arrangement  for  lateral  trac- 
tion.    Practically  speaking,  this  is  a  tape  by  which  the  lower 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


357 


third  of  the  thigh  is  held  in  apposition  to  the  upright.  It 
hardly  seems  possible  that  appreciable  lateral  traction  can  be 
exerted  on  the  joint  by  this  means  if  the  metallic  ring  is 
properly  fitted  to  the  thigh.     The  simple  straps  do  not  afford 


Fig.  242. 


Fig.  2^3. 


The  long  brace,  with  Thomas  ring 
and  extension  upright,  similar  to 
Phelps'   brace. 


lUar  view  of  brace. 


as  effective  traction  as  the  rack  and  pinion,  nor  is  the  brace,  as 
usually  constructed,  sufficiently  strong  to  bear  the  weight  of  the 
body  without  bending.     It  should  be  stated,  however,  that  this 


358 


OETHOPEDIC  SUEGEEY. 


form  of  brace  is  inteudecl  to  be  used  with  crutches  rather  than 
as  a  walking  appliance. 

Certain  objections  to  this  attempt  to  combine  effective  splint- 
ing with  traction  and  stilting  have  been  urged  by  those  who 
believe  in  the  efficiency  of  the  ordinary  traction  brace.  For 
example,  it  is  said  that  the  splinting  is  ineffective  because  the 
movements  of  the  trunk  are  transmitted  to  the  joint,  while  this 
is  not  true  of  braces  that  do  not  extend  above  the  pelvis. 


Fig.  244. 


Fig.  245. 


The  Phelps  hip  splint.  A  chair  to  be  used  with  the  long  hip  splint. 
The  patient  sits  upon  the  sound  side,  while  the 
splinted  half  of  the  body  remains  in  the  extended 
position,  the  brace  resting  on  the  floor. 

As  a  matter  of  experience,  it  will  be  found  that  motion  of  the 
upper  part  of  the  trunk  is  absorbed,  as  it  were,  in  the  flexible 
lumbar  region  of  the  spine  before  it  reaches  the  joint.  If,  how- 
ever, such  motion  or  any  motion  causes  discomfort  or  aggravates 
the  symptoms,  the  patient  should  be  confined  in  the  recumbent 
posture  until  the  acute  phase  of  the  disease  has  passed.  It  is 
said  that  the  brace  is  cumbersome,  that  the  patient  cannot  sit 
with  comfort,   and  that  it  prevents  normal   activity.      A   long 


TUBERCULOUS  DISEASE  OF  TEE  HIP-JOINT.  359 

brace  certainly  weighs  more  than  a  short  one,  and  if  a  brace 
prevents  flexion  of  the  hip  and  spine  it  is  evident  that  the 
patient  cannot  sit  with  comfort  in  an  ordinary  chair. 

The  patients  themselves,  however,  make  little  comj^laint  of 
the  brace,  even  when  it  has  been  substituted  for  an  ordinary 
traction  splint ;  while  the  greater  restraint  of  activity  is  a  favor- 
able element  of  treatment,  since  children  who  do  not  suifer  pain 
are  much  more  likely  to  be  too  active  than  to  be  harmfully  re- 
strained by  any  form  of  appliance.  These  objections  are  trivial 
if  one  is  convinced  that  the  dangerous  and  deforming  disease 
that  is  under  treatment  may  be  more  easily  controlled  and  that 
the  final  result  is  likely  to  be  better  and  to  be  more  rapidly 
attained  by  this  means  than  by  another. 

The  Thomas  Treatment  of  Hip  Disease. — H.  O.  Thomas,^  of 
Liverpool,  writing  at  a  time  when  in  America  it  was  generally 
believed  that  motion  was  essential  to  the  well-being  of  a  diseased 
joint,  and  when  fixation  was  supposed  to  predispose  to,  or  to 
actually  induce,  anchylosis,  states  "  that  continuity  of  exten- 
sion per  se  is  not  a  remedy  in  hip-joint  disease;  in  its  applica- 
tion it  involves  unavoidably  a  fractional  degree  of  fixation 
which  is  sufficient  to  mask  the  evil  of  this  ridiculous  mal- 
practice." 

The  conclusions  on  which,  his  treatment  is  founded  are  these : 
"  The  main  obstacle  to  the  cure  of  an  inflamed  joint  is  the 
friction  and  pressure  of  its  surfaces ;  consequently  the  attain- 
ment of  rest,  that  is  of  immobility  of  the  articulation,  ought  to 
be  the  principle  which  should  guide  the  treatment.  Pressure 
and  concussion  are  less  to  be  'feared  than  friction.  Effectual 
rest  can  only  be  obtained  by  mechanical  treatment,  and  for  this 
purpose  the  appliances  which  I  here  recommend  are  effectual. 
The  more  an  inflamed  joint  is  moved  the  stiff er  does  it  become; 
while  the  more  effectually  it  is  fixed,  the  sooner  and  the  more 
completely  is  its  capability  of  movement  restored.  To  ensure 
permanency  of  cure  the  control  should  be  maintained  for  a 
period  beyond  the  time  when  resolution  has  taken  place.  This 
prolonged  arrest  of  a  joint's  movements,  for  even  an  unneces- 
sarily long  period,  I  have  never  found  to  do  harm." 

The  splint  used  by  Mr.  Thomas  to  carry  out  these  principles 
effectively  is  described  by  him  substantially  as  follows : 

A  flat  piece  of  malleable  iron,  three-quarters  of  an  inch  wide 

^  Diseases  of  the  Hip,  Knee,  and  Ankle-Joints  Treated  by  a  New  and 
Effective  Method,  1875,  p.  10. 


360 


OETEOPEDIC  SUEGEET. 


and  three-sixteeuths  of  an  inch  thick  for  children,  and  one  inch 
by  one-quarter  inch  for  adults,  long  enough  to  extend  from  the 
lower  angle  of  the  scapula  to  the  middle  of  the  calf,  forms  the 
upright.  This  is  fitted  to  the  body  of  the  patient,  passing  from 
the  lower  angle  of  the  scapula,  in  a  perpendicular  line,  down- 
ward, over  the  lumbar  region,  across  the  pelvis,  slightly  ex- 
ternal, but  close  to  the  posterior  spinous  process  of  the  ilium 


Fig.  247. 


The  Thomas  hip  splint,  covered  and  fitted  with  shoulder 
straps.      (Ridlon   and   Jones.) 

and  the  i^rominence  of  the  buttock,  along  the 
course  of  the  sciatic  nerve  to  a  point  slightly 
external  to  the  calf  of  the  leg.  It  must  be  care- 
fully modelled  to  this  track.  The  lumbar  por- 
tion of  the  upright  must  be  invariably  almost  a 
The  splint  in  its  pl^ue  surf  acc,  but  it  must  be  twisted  slightly  on 
simplest  form,  not  its  long  axis  at  the  junction  of  the  upper  and 
ered^'^*^(RwionT^'  middle  third,  so  that  the  anterior  surface  of  the 
lower  part  may  look  slightly  outward  to  corre- 
spond to  the  contour  of  the  buttock  and  thigh.  A  second  and 
double  bend  is  made  in  the  upright  at  the  point  where  it  passes 
the  buttock,  so  that  the  thigh  part  lies  on  a  slightly  higher  plane 
than  the  body  part,  but  parallel  with  it.  The  upright  is  then 
provided  with  chest,  thigh,  and  leg  bands  (Fig.  2-iG). 

The  chest  band  is  of  hoop  iron,  one  and  a  half  inches  in  width 
by  one-eighth  of  an  inch  in  thickness.  This  is  bent  into  an  oval 
to  correspond  with  the  shape  of  the  chest,  being  four  inches  less 
than  the  circumference  at  this  point  if  the  patient  is  an  adult, 
and  of  a  corresponding  size  for  a  child.  It  is  riveted  to  the 
upper  extremity  of  the  brace,  so  that  one-third  of  its  leng-th  shall 
be  on  the  side  corresponding  to  the  diseased  joint  and  two-thirds 


TUBERCULOUS  DISEASE  OF  THE  HIP^JOINT. 


361 


on  the  other.  The  thigh  band  and  leg  band  are  of  similar 
material,  three-qnarters  by  one-eighth  of  an  inch  in  size.  The 
thigh  band,  in  length  equal  to  two-thirds  of  the  circumference 
of  the  thigh,  is  fastened  to  the  upright  at  a  poiut  one  to  two 
inches  below  the  buttock,  and  the  calf  band,  equal  in  length  to 
half  the  circumference  of  the  leg  at  the  calf,  is  riveted  to  the 
lower  extremity  of  the  brace.    Both  the  thigh  and  leg  bands  are 

Fig.  248. 


Method  of  changing  the  line  of  pressure  on  the  sliin  from  the  Thomas  hip  splint 
by  drawing  the  tissues  to  one  side.      (Ridlon  and  Jones.) 


attached  to  the  brace  at  points  slightly  to  the  inner  side  of  the 
centre,  so  that  the  outer  arm  of  each  band  is  somewhat  longer 
than  the  inner.  The  brace  is  padded  with  thin  boiler  felt  and 
is  covered  smoothly  with  basil  leather.  In  fitting  the  brace  to 
the  patient  the  long  part  of  the  chest  band  should  be  made  to 
hug  the  body  closely,  while  the  short  arm  should  be  somewhat 
away  from  it.  The  anterior  surface  of  the  thigh  part  of  the 
upright  should  have  a  perceptible  outward  twist  and  should  be 
somewhat  on  the  inner  side  of  the  popliteal  space.  Thus  the  in- 
strument is  prevented  from  rotating  outward  and  becoming  a 
side  splint.  The  chest  band  is  closed  with  a  strap  and  buckle ;  it  is 
suspended  by  shoulder  straps,  and  the  leg  between  the  two  bands  is 
attached  to  the  brace  by  means  of  a  flannel  bandage.     Eidlon 


362  OBTEOPEUIC  SUBGEBY. 

states  that  in  practice  this  bandage  is  usually  replaced  by  a  strip 
of  basil  leather  passed  across  the  front  of  the  limb  close  down 
to  the  upper  border  of  the  patella,  thence  backward  and  down- 
ward to  the  stem  of  the  splint  and  pinned  to  the  covering,  so 
that  the  resistance  to  the  downward  working  of  the  brace  is 
borne  by  the  quadriceps  femoris  muscle.  The  ordinary  shoulder 
straps  may  be  replaced  by  a  single  bandage  looped  about  the 
upper  part  of  the  stem  (Fig.  2-i8).  This  bandage  is  twisted 
for  a  length  of  about  six  inches,  then  separated,  the  ends  being 
carried  over  the  shoulders,  are  passed  through  holes  in  the  corre- 
sponding ends  of  the  chest  band,  where  they  are  knotted,  and 
finally  the  two  ends  are  tied  to  one  another,  completing  the  cir- 
cumference of  the  chest  band. 

This  brace  is  fitted  by  the  surgeon  directly  to  the  patient's 
body  as  he  stands  erect.  If  the  limb  is  already  flexed  the  foot 
is  raised  by  blocks  until  the  lumbar  lordosis  is  straightened ;  the 
brace  is  then  bent  to  fit  the  angle  of  deformity  and  is  applied  in 
the  usual  manner. 

The  brace  is  made  of  iron  because  it  is  less  elastic  than  steel, 
and  because  it  can  be  more  easily  twisted  by  wrenches.  It  must 
be  heavy  and  strong  in  order  to  splint  the  part  effectively,  and 
it  can  only  be  an  effective  splint  when  it  is  fixed  in  its  proper 
position  and  exercises  direct  pressure  upon  the  hip- joint.  In 
cases  in  which  the  brace  has  been  properly  adjusted  a  deep 
furrow  should  appear  in  the  buttock  directly  over  the  neck  of 
the  femur.  Once  fitted  to  the  patient  it  is  changed  only  at  in- 
frequent intervals  and  always  by  the  surgeon,  who  is  particu- 
larly careful  not  to  move  the  limb  during  the  active  stage  of  the 
disease. 

The  double  Thomas  hip  splint  is  made  by  joining  two  single 
splints.  These  are  riveted  to  the  chest  band  above  and  are  con- 
nected at  the  lower  ends  by  a  crossbar  unless  the  brace  is  to  be 
used  in  the  reduction  of  deformity.  Care  must  be  taken  that 
the  uprights  pass  to  the  outer  side  and  not  directly  over  the 
posterior  superior  spines  of  the  ilium. 

The  Reduction  of  Deformity  by  the  Thomas  Method. — Preferably 
in  the  treatment  of  children  the  double  brace  is  applied,  the 
sound  limb  being  fixed  in  the  extended  position  while  the  flexed 
limb  is  supported  by  the  other  arm  of  the  brace,  bent  to  the 
angle  of  deformity.  The  patient  is  confined  to  the  bed  and,  as 
the  muscular  spasm  relaxes  under  the  influence  of  enforced  rest, 
the  brace  is  straightened  slightly  by  wrenches  from  time  to  time, 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  363 

at  a  point  opposite  the  joint,  to  conform  to  the  improved  posi- 
tion until  symmetry  is  restored.  In  resistant  cases  this  gradual 
relaxation  is  hastened  by  straightening  the  brace  somewhat  at 
intervals,  to  which  the  attached  limb  must  conform — a  gradual 
forcible  reduction  of  deformity.  According  to  Ridlon  and 
Jones,  the  flexed  limb  is  often  forced  to  conform  to  the  straight 
brace  by  a  temporary  exaggeration  of  the  lumbar  lordosis  which 
lessens  as  the  spasm  subsides  under  treatment. 

Fig.  249. 


Thomas  splint  applied  with  patten  and  crutches. 

The  treatment  is  divided  by  Mr.  Thomas  into  stages : 

1.  A  preliminary  stage  of  rest  in  bed  for  the  reduction  of 
deformity  and  to  allow  for  subsidence  of  acute  symptoms. 

2.  The  patient  is  then  allowed  to  go  about  on  crutches  wearing 
an  iron  patten  at  least  four  inches  in  height  under  the  sound 
foot  (Fig.  249). 

3.  When  all  symptoms  of  disease  have  subsided  and  when 
atrophy  of  the  muscles  is  marked  the  brace  may  be  removed  at 
night. 


364 


OETHOPEDIC  SUEGEEY. 


4.  The  brace  is  finallj  discarded,  but  the  patten  aud  crutches 
are  still  used  in  walking. 

The  records  of  Mr.  Thomas  show  the  average  time  of  confine- 
ment to  the  bed  to  be  twenty-two  weeks,  and  the  average  dura- 
tion of  treatment  twenty-one  months. 

It  is  stated  by  Ridlon^  that  in  actual  practice  these  principles 
were  not  carried  out,  for  nearly  all  the  children  treated  under 
Thomas'  direction  at  the  time  his  observations  were  made  were 
walking  about  without  the  high  patten  and  crutches,  even  before 
the  deformity  had  been  overcome  and  while  muscular  spasm  and 
pain  persisted. 

This  was,  however,  probably  an  exigency  of  practice  among 
the  poor,  and  at  all  events  it  is  in  line  with  Thomas'  contention 
that  pressure  and  concussions  are  less  harmful  than  friction. 

Fig.  250. 


A  form  of  Thomas  brace  employed  in  the  treatment  of  infants.  The  pelvic 
band  assures  better  fixation.  The  screws  at  the  lower  extremity  are  arranged 
to  permit  the  addition  of  a  foot-piece  for  traction. 


Modifications  of  the  Thomas  Brace, — Although  not  so  stated  in 
his  book,  Thomas  used  at  times  a  short  brace  extending  only  to 
the  lower  part  of  the  thigh,  thus  permitting  motion  at  the  knee. 
This  was  apparently  designed  as  a  convalescent  splint,  although 
its  use  was  not  restricted  to  that  class  of  cases.  In  certain  cases 
a  strip  of  iron,  "  the  nurse,"  was  screwed  to  the  lower  extremity 
of  the  long  brace,  prolonging  it  beyond  the  foot  in  order  to  pre- 
vent the  patient  from  bearing  weight  upon  the  limb. 

The  Thomas  brace,  so  effective  in  preventing  and  overcoming 
flexion  deformity,  does  not  prevent  lateral  distortion.  In  fact, 
in  twenty-four  of  the  fifty-eight  patients  examined  by  Ridlon,^ 
adduction  was  present;  a  larger  proportion,  it  would  appear, 
than  would  be  found  in  a  like  number  of  cases  under  treatment 

^  A  report  of  Sixty-two  Cases  of  Hip  Disease  Observed  iu  the  Practice  of 
Hugh  Owen  Thomas,  New  York  Medical  Journal,  October,  4,  1890. 
-  Loc.  cit. 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


365 


with  the  traction  brace.  This  tendency  to  lateral  distortion  may 
be  guarded  against  by  placing  a  half  band  of  material  similar 
to  the  chest  band  about  the  side  of  the  pelvis ;  on  the  same  side 
for  adduction,  on  the  opposite  side  for  abduction  of  the  limb. 


riG.  251. 


Fig.  252. 


Fig.  2=^3. 


Different  forms  of  plaster  supports  used  in  tlie  treatment  of  liip  disease. 


The  Thomas  brace  has  a  great  advantage  over  other  appli- 
ances in  its  simplicity.  It  can  be  made  by  a  blacksmith,  but  it 
must  be  fitted  by  the  surgeon.  This  fitting  requires  great  care. 
In  the  V70rds  of  Mr.  Thomas :  "  The  fitting  although  sometimes 
successful  in  one  visit,  may  at  other  times  occupy  many  days. 
The  surgeon  should  mould,  by  reducing  or  increasing  the 
various  curves,  until  the  instrument  ceases  to  tend  to  rotate,  and 
at  none  of  its  angles  irritates  the  patient."  He  concludes,  in  a 
general  answer  to  the  criticisms  that  have  alwavs  been  made  on 


366  OETHOPEDIC  SUEGEBY. 

the  difficulty  of  adjustment  of  the  appliance,  as  follows:  "What 
I  can  invariably  do  must  be  possible  to  others." 

Treatment  by  Plaster  Supports. — The  treatment  of  hip  disease 
in  the  more  important  clinics  of  this  country  has  greatly  changed 
in  recent  years,  and  fixation  of  the  diseased  joint  is  now  gen- 
erally recognized  as  the  most  important  element  of  mechanical 
treatment,  the  conclusion  of  Thomas  already  quoted. 

There  is  a  further  tendency  to  shorten  the  period  of  complete 
inactivity  and  to  permit  weight  bearing  when  it  causes  no  dis- 
comfort.    Thus,  on  the  one  hand,  to  lessen  the  burden  on  the 

Fig.  254. 


The  short  plaster  spica,  combined  with  traction  used  after  reduction  of 

deformity. 

patient  and  on  the  other  to  check  the  atrophy,  loss  of  growth  and 
muscular  and  ligamentous  relaxation  that  follow  complete  and 
prolonged  disuse  of  the  limb. 

This  modification  of  treatment  as  applied  in  hospital  service 
may  be  outlined  as  follows : 

Deformity,  if  present,  is  at  once  reduced  under  ansesthesia 
by  traction  and  gentle  leverage,  and  the  limb  is  placed  in  full 
extension  and  15  degrees  of  abduction.  Traction  plasters  hav- 
ing been  applied  to  the  limb  a  spica  plaster  support,  reaching 
from  the  ankle  to  the  mammary  line,  carefully  moulded  about 
the  pelvis  and  hip,  is  adjusted.  The  patient  is  then  placed  in 
bed  with  a  traction  weight  of  ten  pounds  or  more.  This  treat- 
ment is  continued  until  all  acute  symptoms  have  subsided,  a 
wheeled  couch  on  which  the  patient  lies  talking  the  place  of  the 
bed  during  the  day.  The  immediate  correction  of  deformity 
followed  by  fixation  in  the  desired  attitude  has  a  manifest  ad- 
vantage over  the  tedious  reduction  by  traction  which  necessitates 


TUBEBCULOUS  DISEASE  OF  THE  RIP-JOINT.  367 

long  confinement  to  the  bed  with  no  compensatory  advantages 
except  the  avoidance  of  a  so-called  operation  (Fig.  261). 

After  several  v^eeks  or  months,  weight  bearing  is  tested  and 
if  it  causes  no  immediate  or  subseqnent  discomfort  it  is  per- 
mitted.    If  the  joint  is  sensitive  to  weight  bearing,  although  it 

Fig.  255. 


The  long  plaster  spica  bandage.     The   dotted   line   indicates   the  position  of  the 

steel    support. 

causes  no  actual  pain,  axillary  crutches  or  a  perineal  splint  may 
be  used  for  a  time.  As  soon  as  the  indications  permit,  the  long 
spica  is  replaced  by  the  Lorenz  plaster  support,  permitting 
motion  at  the  knee  and  in  the  lumbar  spine,  but  supporting  the 
joint  by  accurate  adjustment  to  the  pelvis.    With  this  appliance 


368 


OBTHOPEDIC  SUEGEEY. 


a  certain  degree  of  flexion  of  the  limb  can  not  be  prevented,  nor 
is  it  within  limits  undesirable  when  weight  bearing  is  permitted, 
as  it  lessens  the  direct  jar  on  the  joint.     With  care  the  attitude 


Fig.  256. 


The   Schultze  pelvic  support   for   the  application   of  the  plaster   spica. 

of  abduction  mav  be  assured.    This  is  of  the  greatest  importance, 
for  when  the  head  of  the  femur  lies  deep  in  the  acetabulum 

Fig.  2.57. 


Box  with  adjustable  sacral   support   of  the  T.orenz   model   used  for  the 
application  of  the  plaster  spica. 


direct  pressure  is  removed  from  its  up]ier  surface  and  the  corre- 
sponding surface  of  the  acetabulum,  those  points  which  most 
often  present  evidence  of  pressure  erosion. 


TUBEECULOUS  DISEASE  OF  TEE  HIP-JOINT. 


369 


If  the  patient  is  seen  early  before  deformity  has  appeared  the 
short  spica  is  applied  without  preliminary  traction  and  locomo- 
tion is  permitted  if  the  symptoms  indicate  that  the  joint  will 
tolerate  it. 

This  treatment  in  which  the  degree  of  protection  is  adapted 
to  the  character  of  the  disease  differs  from  that  of  Lorenz,  which 
is  practically  a  routine  ambulatory  treatment  by  the  short  spica, 
as  decidedly  as  from  the  routine  treatment  by  braces. 

The  principles  are  those  that  govern  the  treatment  of  tuber- 

FiG.  258. 


A  pelvic  support  in  use.     The  patient  presents  fixed  flexion  to  135  degrees,  and 
fixed  adduction  of  35  degrees. 


culous  disease  of  the  lungs,  periods  of  rest  alternating  with  an 
activity  regulated  by  the  symptoms.  It  is  a  compromise  be- 
tween the  treatment  of  the  local  disease  and  the  effect  of  this 
treatment  upon  the  limb  and  upon  the  patient.  Thus,  acute 
symptoms  at  any  stage  of  the  disease  indicate  the  long  spica 
and  traction;  discomfort,  a  lessened  activity  and  relief  from 
weight  bearing.  If,  however,  the  local  disease  is  quiescent, 
weight  bearing  without  motion  improves  the  nutrition  of  the 
limb  and  that  of  the  body  in  general. 
24 


370 


OETHOPEDIC  SUSGEEY. 


Applicatiox  of  Plastee  Splixts. — The  long  spica  is  often 
applied  in  out-patient  practice.  It  is  a  better  protection  than 
the  less  comprehensive  fonxis  in  that  it  prevents  movements  of 
the  leg,  diminishes  the  jar  on  a  sensitive  joint  and  enclosing 
the  foot  lessens  the  danger  of  oedema  in  the  exposed  extremity. 


Fig.  259. 


Fig.  260. 


The  short  spica  of  the  Lorenz  type  showing 
the  adjustment  to  the  pelvis. 


Hear  view  of  the  short  spica. 


If,  however,  the  disease  is  acute  rest  in  bed  with  traction  in  the 
manner  described  is  indicated. 

A  plaster  splint  to  assure  support  should  fit  perfectly,  conse- 
quently it  should  be  applied  with  as  little  padding  as  is  prac- 
ticable.    A  covering  of  shirting,  such  as  is  used  in  the  applica- 


TUBEECULOUS  DISEASE  OF  THE  HIP-JOINT. 


371 


tion  of  the  plaster  jacket,  is  fitted  tO'  the  body  and  the  limb 
reinforced  with  one  or  more  layers  of  cotton  flannel  bandage, 
those  parts  that  are  likely  to  be  subjected  to  pressure — the  toes, 
the  heel,  the  malleoli,  the  condyles  of  the  femur,  the  sides  of  the 
pelvis,  the  anterior  superior  spines,  and  the  thorax — being 
further  protected  by  cotton  wadding  or  other  material.  The 
plaster  bandage  should  cover  the  lower  half  of  the  thorax,  and  it 
should  extend  to  the  ends  of  the  toes.    It  should  be  applied  under 

Fig.  261. 


The  spica  with  traction  and  the  wheeled  couch  used  at  the  Hospital  for  Ruptured 

and  Crippled. 


slight  traction,  very  carefully  around  the  adductor  region  and 
reinforced  beneath  the  buttock,  which  should  be  entirely  covered 
and  supported.  At  this  point,  in  the  line  in  which  the  bar  of 
the  Thomas  hip  splint  runs,  a  piece  of  splint  wood  or  a  strip  of 
malleable  steel,  long  enough  to  reach  from  the  middle  of  the 
trunk  to  the  lower  third  of  the  thigh,  should  be  incorporated  in 
the  plaster  (Fig.  255).  A  similar  piece  is  sometimes  placed  in 
front  of  the  hip  and  another  beneath  the  knee,  the  points  at 


372  OETHOPEDIC  SOEGEBY. 

wbiclt  the  support  is  likely  to  break  before  it  becomes  firm.  Tbe 
proper  anteroiDosterior  support  of  tbe  buttock,  consequently  of 
the  bip-joint,  which  is  of  tbe  first  importance,  is  almost  invari- 
ably neglected  in  the  ordinary  application.  The  spica  may 
be  applied  in  the  upright  posture  by  means  of  the  swing,  as 

Fig.  262. 


The  Lorenz  spica,  showing  tlie  adjustment  to  tlie  pelvis.  In  this  case  it  is 
extended  below  the  knee,  but  in  many  instances  motion  at  the  knee-joint  is 
permitted. 

used  in  the  application  of  the  plaster  jacket,  the  weight  being 
supported  in  part  by  the  sound  leg  while  the  other  is  pendent. 
Usually  it  is  applied  with  the  patient  in  the  reclining  posture. 


TUBEECULOUS  DISEASE  OF  THE  HIP-JOINT. 


;373 


the  body  lying  on  a  shoulder  rest,  and  a  sacral  support.  The  arms 
are  then  drawn  above  the  head  to  increase  the  capacity  of  the 
thorax,  while  the  limbs  are  supported  by  an  assistant  (Fig. 
258). 

In  the  more  recent  cases,  deformity  may  be  practically  reduced 
at  the  second  application  of  the  bandage,  because  of  the  relaxa- 

Fi<;.  2G3. 


Fig.  264. 


The  Lui-fii/,  spica  Willi  liir  iicriiical 
band.  A  shoe  with  a  cork  sole 
should  be  worn  on  the  abducted  side. 


The  Lorenz  stilt,  sometimes  used  in 
the  treatment  of  the  more  painful  cases. 
This  is  incorporated  in  the  plaster  band- 
age above  the  knee  and  it  extends  below 
the  foot. 


tion  of  the  spasm  assured  by  the  rest  and  fixation;  thus  it  is 
particularly  useful  in  the  treatment  of  young  children  in  the 
outdoor  practice,  for  whom  hospital  care  would  otherwise  be 
required. 


374 


ORTHOPEDIC  SUBGEBY. 


The  Shokt  oe  Loeenz  Spica. — The  short  spica  is  used  as 
routine  treatment  of  hip  disease  in  Lorenz's  clinic  in  Vienna  and 
in  a  somewhat  modified  form  this  principle  of  treatment  has 
been  accepted  in  many  of  the  clinics  in  this  country,  the  aim 
being  to  fix  the  affected  limb  in  an  attitude  of  slight  flexion  and 
abduction,  the  primary  attitude  of  hip  disease  by  accurate  ad- 
justment to  the  pelvis  and  at  the  same  time  permitting  movement 
in  the  lumbar  spine  and  at  the  knee.  A  close-fitting  covering  of 
shirting  is  drawn  over  the  limb  and  pelvis,  and  a  wide  friction 
bandage  is  then  introduced  between  the  skin  and  shirting  to 

Fig.  265. 


The  short  spica  bandage  reaching  to  the  knee  in  combination  with  the  long 
ti'action  brace.  One  perineal  band  has  been  removed  in  order  to  show  how  the 
joint  is  supported  by  the  bandage. 

serve  as  a  "  scratcher."  The  bony  prominences  are  suitably 
protected  in  the  manner  described,  and  the  bandages  are  then 
applied,  being  drawn  closely  and  carefully  moulded  about  the 
pelvis  and  thigh,  so  that  movement  in  the  joint  may  be  con- 
trolled. The  upper  and  lower  extremities  of  the  bandage  are 
cut  away  as  illustrated  (Fig.  259),  and  the  shirting  is  then 
drawn  over  the  margins  of  the  plaster  and  sewed.  This  makes 
a  smooth  covering  and  holds  the  padding  in  position.  If  the 
bandage  is  extended  below  the  knee  it  is  more  efficient  in  check- 
ing the  action  of  the  long  muscles  which  are  attached  to  the 
pelvis  and  to  the  leg.  It  should  be  stated  that  in  the  treatment 
of  some  of  the  more  acute  cases  by  Lorenz  the  weight  of  the  body 
is  removed  by  a  prolongation  or  stirrup  of  sheet  steel  which 
projects  beyond  the  foot,  the  two  extremities  being  incorporated 
in  either  side  of  the  plaster  bandage  in  the  neighborhood  of  the 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


375 


knee  (Fig.  264).  In  the  better  class  of  cases  a  leather  support 
provided  with  a  steel  foot-plate  extending  slightly  below  the  foot 
and  a  joint  at  the  knee  is  used  in  German  clinics.  The  short 
spica  bandage  in  combination  with  the  traction  hip  brace  (Fig. 


Fig.  266. 


Tlie  Lorenz  spica  combined  witli  the  traction  hip  brace.     The  perineal  strap 
prevents  displacement  of  the  plaster  appliance. 


266)  answers  the  same  purpose  and  is  more  efficient  if  some- 
what more  cumbersome. 

The  importance  of  the  attitude  of  moderate  abduction  has  been 
mentioned.  To  assure  this  position  the  lateral  elevations  of  the 
spica  should  overlap  the  short  ribs  and  if  necessary  a  perineal 
band  may  be  used  as  illustrated  in  the  figure  (Fig.  263).    A  cork 


376 


OETEOPEDIC  SUBGEBY. 


sole  of  about  an  inch  in  thickness  may  be  used  on  the  abducted 
side  to  prevent  tilting  of  the  pelvis. 

The  advantages  of  immediate  correction  of  deformity  under 
anaesthesia  have  been  mentioned.  It  should  not  be  employed  if 
the  deformity  is  of  long  standing  and  if  the  disease  is  active 

Fig.  267. 


Lateral    view.     The    shape    of    the    pelvic    band    is    like  that  illustrated 
in  Fig.   269. 


or  of  the  destructive  type  accompanied  by  infiltration  of  the 
tissues  or  by  discharging  sinus.  In  such  cases  traction  is  to  be 
preferred  and  in  certain  instances  in  which  because  of  general 
shortening  of  the  contracted  tissues  and  subluxation  of  the 
femur,   reduction  by  this  method  is   impracticable,   correction 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


377 


Fig.  268. 


should  be  deferred  until  the  process  of  repair  is  practically 
completed. 

The  impression  that  one 
might  receive  from  descriptions 
of  the  treatment  of  hip  disease 
is  that  most  cases  begin  acutely, 
or  that  when  the  patients  are 
brought  for  treatment  the  dis- 
ease is  in  an  acute  stage,  or 
that  deformity  is  present,  so 
that  preliminary  recumbency  is 
required.  But  each  year  the 
proportion  of  early  cases  is 
greater,  cases  in  which  there  is 
no  deformity  and  in  which 
acute  symptoms  are  absent.  In 
such  instances  the  hip  splint  or 
plaster  spica  may  be  applied 
without  preliminary  recum- 
bency, and  if  the  joint  is  fixed 
in  the  normal  attitude  and  pro- 
tected a  relatively  rapid  recov- 
ery without  deformity  and  with 
a  fair  range  of  motion  may  be 
hoped  for. 

Review  of  the  Mechanical 
Treatment — Traction  is  the 
most  efficient  means  of  assuring 
rest  of  a  diseased  joint  if  the 
patient  is  recumbent  or  if  the 
limb  is  pendant.  Under  careful 
and  constant  supervision  some 
traction  may  be  exerted  by  an 
ambulatory  splint,  but  under 
ordinary  conditions  the  traction 
hip  brace  is  only  efficient  as  a 
stilt  in  relieving  the  pressure  and  shock  of  weight  bearing.  It 
does  not  prevent  motion  at  the  joint  nor  does  the  traction  pre- 
vent friction. 

The  most  accurate  statistics  of  final  results  in  cases  treated 
by  this  aiDparatus  illustrate  also  its  ineffectiveness  in  preventing 
deformity.     Thus  in  a  total  of  thirty-five  cases  treated  at  the 


The  Taylor  hip  splint  as  used  by 
Taylor  in  the  later  years  of  his  prac- 
tice with  but  one  perineal  band.  The 
illustration  shows  also  an  appliance 
for  preventing  or  for  correcting 
slight  degrees  of  adduction,  while  the 
brace  is  in  use  as  a  walking  appli- 
ance. The  abduction  bar  is  buckled 
about  the  upper  extremity  of  the 
other  thigh.  (H.  L.  Taylor,  Medical 
N&ws,  March  23,  1889.) 


378 


OETHOPEDIC  SUE  GEE  Y. 


]Sr.  Y.  Orthopedic  Dispensary-^  practical  ancliylosis  was  present 
in  74:^  and  in  60"  tlie  limb  was  distorted  to  a  greater  or  less 
degree. 

The  Bradford  brace,  if  properly  adjusted,  holds  the  limb  in 
abdnction  and  indirectly  splints  the  joint.     It  is  therefore  the 
most  efficient  of  the  short  traction  braces. 
.    The  long  traction  brace  adds  the  element  of  splinting  in  which 

Fig.  269. 


Taylor's  median  abduction  brace  used  as  a  bed  splint  to  overcome  adduction  by 
counterpressure  upon  the  sound  side. 

the  short  braces  are  deficient  and  it  is  therefore  far  more  satis- 
factory in  the  treatment  of  the  acute  or  destructive  types  of  cases. 

*  Shaffer  and  Lovett,  New  York  Medical  Journal.  March  2,  1878. 


OBTHOPEDIC  SUBGEET.  379 

The  Thomas  brace  is  a  direct  splint  and  iixes  the  joint  more 
-perfectly  than  other  braces,  but  it  does  not  prevent  adduction 
nor  does  it  provide  traction,  v^hich,  in  connection  with  crutches, 
may  be  an  important  adjunct  in  treatment. 

Plaster  supports  enable  one  to  dispense  with  the  services  of  a 
mechanic,  a  great  advantage  in  many  instances.  The  long  spica 
with  traction  in  recumbency  is  the  most  satisfactory  treatment 
for  acute  disease.  The  long  spica  including  the  foot  is  of  service 
in  the  treatment  of  young  children  in  out-patient  practice. 

The  short  spica  is  efficient  in  selected  cases  in  proportion  to 
the  accuracy  of  its  adjustment. 

The  vexed  question  is  that  of  early  weight  bearing,  as  opposed 
to  complete  cessation  of  function,  from  the  inception  to  the  end 
of  the  disease,  a  period  of  several  years. 

From  the  practical  standpoint,  what  has  been  described  as  the 
treatment  by  plaster  supports  is  far  more  satisfactory  both  to 
patient  and  surgeon  than  the  old  routine  treatment  by  the  traction 
brace.  A  comparison  of  final  results  is  however  impracticable. 
It  is  claimed  that  splinting  and  weight  bearing  will  favor  anchy- 
losis. If  the  surfaces  of  the  femur  and  of  the  acetabulum  are 
denuded  of  cartilage  and  are  held  in  apposition,  the  process  of 
repair  should  cause  adhesion,  fixation  and  cure,  as  contrasted 
with  deformity  and  subluxation,  which  would  separate  the 
mutually  diseased  surfaces.  Under  such  conditions  anchylosis, 
which  is  the  best  assurance  of  cure  and  future  comfort  is  an  end 
to  be  desired  rather  than  avoided.  Loss  of  motion  is  moreover 
very  common  in  cases  treated  by  contrasting  methods.  For  ex- 
ample, in  a  series  of  cases  illustrating  final  results  treated 
exclusively  by  the  traction  hip  splint,  there  was  practical  fixation 
in  74  per  cent.-^  It  may  be  assumed  also  that  efficient  splinting 
of  the  joint  with  the  limb  in  an  attitude  of  selection,  combined 
with  modified  weight  bearing,  is  more  likely  to  check  the  de- 
structive changes  in  the  joint  than  is  stilting  with  inefficient 
splinting. 

Weight  bearing  should  not  be  permitted  if  it  causes  discom- 
fort, or  if  abscess  is  present,  or  if  the  disease  is  of  a  destructive 
type.  In  such  cases  the  long  traction  brace  is  the  most  satisfac- 
tory appliance.  The  best  treatment  is  that  which  is  adapted  to 
the  patient's  surroundings  and  to  his  general  and  local  condition, 
a  treatment  therefore  of  selection  as  opposed  to  one  of  routine. 

Treatment  during  Stage  of  Recovery. — It  is  much  easier  to 
assure  one's  self  that  the  disease  is  still  active  than  to  decide 

^  Locus  cit.' 


380 


OBTHOPEDIC  SUEGEBY. 


Fig.  270. 


when  it  is  cured.  For  the  symptoms  may  have  been  quiescent 
for  months  or  years  even,  under  the  protective  treatment,  and 
yet  they  may  recur  on  the  slightest  provocation  v^hen  this  treat- 
ment has  been  discontinued. 

To  judge  of  the  probable  dura- 
tion of  the  disease  in  a  given 
case,  one  must  consider  its  area, 
its  quality,  and  its  complications. 
If,  for  example,  the  primary 
symptoms  indicate  that  the  focus 
of  infection  is  of  limited  area 
and  is  contained  within  the  bone, 
rapid  recovery,  possibly  in  a 
year,  may  be  expected ;  but  in 
the  ordinary  type  of  disease  in 

Fig.  271. 


Modified  brace  to  be  worn  during 
convalescence.  Same  patient  as  in 
Fig.  242.  The  thoracic  part  has  been 
removed  and  the  lower  end  of  the 
stem  has  been  made  into  a  caliper,  pass- 
ing through  the  heel  of  the  shoe.  The 
stem  is  extended  by  means  of  the  key 
until  the  heel  is  lifted  slightly  from 
the  shoe ;  thus  the  hip  is  relieved  from 
shock. 


Judson's  perineal  crutch.  This  sup- 
port suspended  from  the  shoulders 
may  be  employed  as  a  substitute  for 
axillary  crutches.  It  Is  also  used  as 
a  convalescent  splint  in  the  treatment 
of  hip  disease. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


381 


Fig.  27.^. 


which  the  joint  has  been  invaded,  repair  can  hardly  be  antici- 
pated in  less  than  three  or  four  years.  If  sufficient  time  has 
elapsed  to  permit  of  natural  cure,  if  there  have  been  no  symp- 
toms of  active  disease  for  a  year  or  more,  and  if  muscular  spasm 
is  absent,  one  may  test  the  joint  by  removing  the  brace  at  night 
to  ascertain  the  effect  of  simple  motion  without  weight  bearing. 
Such  freedom  will  enable  the  patient  to 
move  the  knee,  which  if  it  has  been 
fixed  in  the  extended  position  usually 
remains  stiff  for  a  time ;  in  fact,  several 
months  may  elapse  before  the  full  range 
of  motion  is  regained. 

It  is  well,  also,  if  the  long  splint  has  ' 
been  used,  to  remove  the  thoracic  part  to 
permit  mobility  at  the  hip.  At  a  later 
time  the  traction  may  be  discontinued 
and  the  brace  may  be  suspended  from 
the    shoulders    to   serve    as    a   perineal 

Fig.  272. 


Convalescent  hip  splint,  allowing  motion  at  tiie  knee.      (Taylor.) 


crutch  (Fig.  271)  ;  or  it  may  be  attached  to  the  shoe  and  so 
adjusted  as  to  be  slightly  longer  than  the  limb,  in  order  that 
direct  concussion  and  pressure  may  be  lessened  (Fig,  270).  Or 
a  brace  jointed  at  the  knee,  after  the  Taylor  pattern,  may  be 
employed. 

This  brace  is  so  adjusted  as  to  be  slightly  longer  than  the 


382 


TUBEECULOUS  DISEASE  OF  THE  HIP-JOINT. 


limb,  so  that  the  heel  does  not  touch  the  bottom  of  the  shoe  (Fig. 
273).  Thus  the  weight  is  in  great  part  supported  on  the  perineal 
band.  The  weight  of  the  brace  may  be  in  part  supported  and 
incidentally  slight  traction  may  be  exerted  by  adhesive  plaster 
applied  above  the  knee  (Fig.  274).  The  foot-plate,  to  which 
the  upright  is  attached,  is  shown  in  Figs.  273  and  275. 


Fig.  274, 


Fig.  275. 


Fig.  276. 


Details  of  the  Taylor  convalescent  hip 
brace.  Fig.  274,  the  adhesive  plaster.  Fig. 
275,  the  foot-plate  showing  the  method  of 
attachment. 


The  action  of  the  Taylor  con- 
valescent hip  brace  in  removing 
direct  pressure  illustrated  by 
wooden  model. 


As  the  strain  upon  the  part  is  increased,  one  watches  carefully 
for  the  return  of  muscular  spasm  or  for  restriction  of  the  range 
of  motion.  If  the  range  of  motion  does  not  diminish,  and  if  the 
deformity  that  may  be  present  does  not  increase  or  does  not 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  383 

appear  if  it  were  absent,  the  brace  may  be  removed  at  intervals 
and  finally  discarded. 

As  has  been  stated,  the  short  spica  after  the  Lorenz  model  is 
an  admirable  support  during  the  period  of  recovery.  It  checks 
motion  at  the  joint,  yet  it  permits  the  function  of  support,  and 
thus  a  gradual  rebuilding  of  the  bony  structure  which  has  be- 
come atrophied  during  the  course  of  the  disease.  By  means  of 
this  appliance  the  limb  may  be  held  in  the  desired  position  of 
slight  abduction,  and  it  is  particularly  effective  when  the  limb, 
because  of  destructive  changes  in  the  joint,  is  inclined  toward 

Fig.  277. 


Double  hip  disease,  terminating  in  bony  anchylosis. 

adduction.  It  should  be  stated  that  the  long-continued  fixation 
of  the  limb,  especially  if  combined  with  traction,  may  induce 
laxity  of  the  ligaments  and  hyperextension  at  the  knee,  unless  it 
is  properly  supported  by  the  posterior  thigh  band.  In  the  cases 
in  which  the  atrophy  is  extreme  and  in  which  this  laxity  is 
present  the  splint  may  be  discarded  in  favor  of  the  plaster 
support  with  advantage  (Fig.  278). 

This  period  of  supervision  even  in  favorable  cases  should  be 
protracted,  for  no  patient  can  be  considered  free  from  the  danger 


384 


OBTROPEDIC  SUBGEBY. 


of  relapse  for  a  long  time  after  apparent  cure.  If  there  is  firm 
bony  union,  as  in  exceptional  cases,  cure  is  assured ;  but  if  there 
is  simple  fibrous  anchylosis,  and  particularly  if  there  is  upward 


Fig.  278. 


Hypei'extension  at  the  knee  following  disease  of  the  hip-joint  and  Its  treatment 
by   the    traction   brace. 


displacement  of  the  trochanter,  there  is  a  strong  tendency  toward 
flexion  and  adduction,  even  though  the  disease  is  cured.  This 
tendency  should  be  resisted  by  persistent  "  stretching "  in  the 
directions  of  abduction  and  extension  and  if  necessary  apparatus 
must  be  again  applied  to  reduce  the  deformity  or  to  hold  the 
limb  in  proper  position  until  stability  is  assured.  When  the 
brace  or  plaster  has  been  discarded,  the  patient  should  be  trained 
to  walk  with  equal  steps,  placing  the  limb,  as  far  as  possible,  on 
an  equality  with  its  fellow  and  adapting  in  like  manner  the 
stronger  to  the  weaker  member. 

This  has  an  important  influence  in  checking  the  tendency  to 
deformity  and  in  modifying  or  even  concealing  the  limp,  a  point 
to  which  Judson  has  repeatedly  called  attention. 

Bilateral  Hip  Disease. — ISTinety-five  cases  of  bilateral  hip  dis- 
ease were  treated  in  the  Hospital  for  Ruptured  and  Crippled 
during  a  period  of  ten  years. 


TUBERCULOUS  DISEASE  OF  TEE  HIP-JOINT. 


385 


As  a  rule,  the  second  hip  is  affected  some  time  after  the  symp- 
toms of  disease  of  the  first  have  been  apparent,  but  occasionally 
both  joints  are  involved  simultaneously.  In  most  instances  the 
symptoms  are  rather  subacute,  owing,  very  likely,  to  the  fact 
that  the  activity  of  the  patient  is  so  restricted. 

Treatment, — The  treatment  is  similar  in  principle  to  that  of 
the  unilateral  form.  The  patient  during  the  greater  part  of  the 
course  of  the  disease  must  be  confined  in  the  recumbent  position, 
although  not  necessarily  in  bed.     The  double  Thomas  hip  splint 


Fig.  279. 


Left  hip   disease,    shuwiiu 


swelling   caused   by   abscess,   also  the   absence   of 
flexion  deformity. 


or  spica  plaster  support  may  be  used.  If  the  disease  is  acute 
traction  is  added  in  the  manner  already  described.  If  the  dis- 
ease of  one  hip  is  acute  and  is  attended  by  abscess  formation, 
excision  for  the  purpose  of  lessening  the  strain  upon  the  patient 
may  be  advisable. 

If  motion  is  greatly  restricted  in  both  joints  locomotion  unless 
crutches  are  used  is  very  difficult  as  motion  at  the  knees  can 
supply  only  in  small  part  the  function  of  the  hip-joints.  In 
such  instances  excision  of  one  hip  with  the  aim  of  obtaining  a 
certain  amount  of  motion  may  be  considered. 

Hip  Disease  Combined  with  Disease  of  Other  Parts. — The 
most  common  combination  is  with  Pott's  disease.  The  two 
processes  may  be  distinct,  but  occasionally  it  would  appear  that 
the  disease  of  the  hip  is  caused  by  the  infection  of  an  abscess, 
which,  coming  from  the  spine,  remains  for  a  long  time  in  con- 
tact with  the  capsule  of  the  joint.  In  five  of  one  hundred  and 
fifty  cases  of  disease  of  the  hip-joint  of  which  the  final  results 
were  reported  by  Gibney,  Waterman,  and  Reynolds  (page  405), 
25 


386 


ORTHOPEDIC  SURGE  BY. 


Fig.  280. 


Pott's  disease  was  a  complication,  in  two  instances  preceding 
and  in  three  following  the  disease  at  the  hip.  The  combination 
of  the  two  diseases  makes  the  mechanical  treatment  difficult. 

Recumbency  offers  the  best  op- 
portunity for  the  effective  ad- 
justment of  apparatus  when  the 
disease  of  either  part  is  acute. 
At  a  later  period  crutches  may 
be  employed,  together  with  the 
necessary  braces. 

Hip  Disease  in  Infancy. — Hip 
disease  in  infancy  is  far  less 
common  than  in  early  childhood. 
It  presents  nothing  of  special  in- 
terest except  that  its  effect  upon 
the  function  of  the  joint  and 
upon  the  development  of  the  limb 
is  usually  more  marked  than  in 
older  subjects.  Tuberculous  dis- 
ease of  this  joint  must  be  differ- 
entiated from  infectious  epiphy- 
sitis, in  which  prompt  operative 
treatment  is  indicated.  A  modi- 
fied Thomas  brace  is  most  effi- 
cient in  treatment  (Fig.  250). 

Hip  Disease  in  the  Adult — 
Hip  disease  in  the  adult  may 
present  the  typical  symptoms  of 
the  ordinary  form,  but  it  is  usu- 
ally of  the  more  subacute  type. 
]^ot  infrequently  it  is  a  compli- 
cation of  tuberculosis  of  the 
lungs. 

The  subacute  form  of  tubercu- 
lous disease  is  often  difficult  to 


Untreated  hip  disease.  Sligtit  flex- 
ion and  adduction  (apparent  shorten- 
ing). The  scar  of  a  former  abscess 
is  seen  on  the  outer  aspect  of  the 
thigh. 


distingTiish  from  arthritis  defor- 


mans, if  this  is  limited  to  the 
hip-joint.  Gonorrhoeal  arthritis  and  impacted  fracture  of  the 
neck  of  the  femur  may  be  mentioned  also  in  differential  diag- 
nosis. The  mechanical  treatment  is  not  difficult,  but  early  exci- 
sion or  arthrotomy  to  induce  anchylosis  may  be  advisable  to  hasten 
the  cure  of  the  disease.     This  is  far  more  im]:)ortant  than  in 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  387 

childhood,  because  few  adults  can  afford  the  time  required  for 
the  natural  cure,  and  because  in  many  instances  the  general  con- 
dition of  the  patient  may  demand  relief  from  the  depressing 
tifects  of  the  local  disease,  especially  if  it  be  complicated  by  sup- 
puration. 

Abscess  Complicating  Hip  Disease. — It  may  be  assumed  that 
a  limited  collection  of  the  fluid  products  of  the  tuberculous 
process  is  present  in  nearly  every  case  of  hip  disease  in  which 
the  joint  surfaces  are  actually  involved.  In  many  instances  it 
remains  within  the  joint.  In  a  larger  proportion  of  the  cases 
the  capsule  is  perforated,  the  fluid  escapes,  and,  if  the  quantity 
is  sufficient  to  form  an  appreciable  tumor,  it  is  classed  as  an 
abscess.  Such  abscesses  may  be  detected  in  about  50  per  cent, 
of  the  cases  that  are  treated  under  ordinary  conditions. 

In  1472  final  results  collected  from  various  sources  the  per- 
centage of  abscess  was  as  appears  in  the  foUoiMmg  table : 

39  eases  reported  by  Shaffer  and  Lovett^ 69.0  per  cent. 

82   eases   reported   by   Gibney- 60.0  per  cent, 

390  cases  reported  by  Bruns,^  Tubingen : .  .  .  .  58.3  per  cent. 

568  eases  reported  by  Koenig/  Grottingen 56.5  per  cent. 

125  cases  reported  by  Sasse,^  Berlin 50.0  per  cent. 

82  cases  reported  by  Prendlsburger,^  Vienna 51.0  per  cent, 

98  cases  reported  by  Bradford/  Boston 37.0  per  cent, 

84  cases  in  private  practice,  C.  F.  Taylor^ 25.0  per  cent. 

Most  often  the  abscess  first  appears  upon  the  anterior  and 
upper  part  of  the  thigh,  in  the  space  between  the  sartorius  and 
tensor  vaginae  femoris  muscles.  In  other  instances  it  may  be 
detected  first  on  the  inner  side  of  the  thigh,  or  it  may  form  a 
tumor  beneath  the  gluteal  muscles,  its  situation  being  influenced 
by  the  point  at  which  the  capsule  is  ruptured. 

In  rare  instances  the  acetabulum  may  be  perforated  and  a 
pelvic  abscess  may  be  formed,  or  the  pus  may  find  its  way  into 
the  pelvis  along  the  iliopsoas  muscle ;  and  occasionally  a  pelvic 
abscess  may  exist  which  appears  to  have  no  direct  communica- 
tion with  the  joint. 

The  weakest  point  of  the  capsule  is  in  the  anterior  wall,  where 
it  is  covered  by  the  iliopsoas  muscle  and  by  its  bursa,  which 

'  New  York  Medical  Journal,  May  21,  1887. 
^New  York  Medical  Eecord,  March  2,   1878. 
^Beit.  zur  klin.  Chir.,  1895,  Bd.  xxx. 

*  Die  Spec.  Tuberculose  der  Knoch  u.  Gelenke,  Berlin,  1902. 

^Arbeit  aus  der  Chir.  klin.  der  K.  Univ.  Berlin  (Bergmann's  clinic),  1896, 
'Behand.    der   Gelenktuberculose   und   ihre   Enxlresultate   aus   der   klinik 
Albert,  Wien,  1894. 

'  Am.  Med.  J.  Sci.,  Dec,  1908. 

*  Boston  Medical  and  Surgical  Journal,  March  6,  1879. 


■388 


OBTHOPEDIC  SUBGEBY. 


often  communicate  with  the  joint.     A  second  weak  place  is  in 
the  posterior  wall. 

In  a  total  of  321  abscesses  in  hip  disease  recorded  by  Koenig^ 
the  situation  was  as  follows : 

On  the  inner  side   (inside  the  femoral  artery) 26 

Front  of  the  joint  (between  artery  and  anterior  superior  spine)  126 

Eegion   of  the  trochanter 63 

Posterior  surface   49 

In  the  pelvis    41 

In  other  situations    16 

The  tuberculous  abscess  is  a  symptom  and  common  accom- 
paniment of  hip  disease,  which,  in  cases  treated  under  proper 
conditions,  is  not  of  great  importance ;  and  yet,  on  the  other 

Fig.  281. 


Abscess  in  hip  disease.     The  brace  is  provided  with  the  Thomas  ring  and  with 
the    ratchet    extension. 


hand,  it  is  recognized  as  a  dangerous  complication.  It  is  dan- 
gerous to  life  because  of  the  profuse  suppuration  that  may  fol- 
low infection,  and  to  function  because  of  the  adhesions  and  con- 
tractions that  may  result.  This  is  evident  in  all  statistics.  It 
is  clearly  shown  in  those  of  Bruns,  In  this  list  the  mortality 
in  the  non-suppurative  cases  was  23  per  cent.,  and  of  the  sup- 
purative 52  per  cent. 

Significance.- — If  abscess  appears  early  in  the  course  of  the 
disease,  it  usually  indicates  that  it  is  of  a  destructive  character, 
and  that  the  interior  of  the  joint  is  involved ;  therefore,  function 
is  less  likely  to  be  preserved  than  in  those  cases  in  which  the 
disease  has  been  confined  to  the  interior  of  the  bone. 

Abscess  formation  is  often  preceded  by  pain,  by  an  increase 

^  Loe.  cit. 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  389 

of  muscular  spasm  and  consequent  distortion,  and  often  by  an 
elevation  of  temperature.  These  acute  symptoms  subside  and  a 
fluctuating  swelling  appears.  It  may  be  inferred  that  the  pain 
in  such  a  case  was  due  to  the  tension  of  the  abscess  within  the 
capsule,  and  that  the  relief  of  pain  followed  perforation  and  the 
escape  of  the  fluid. 

In  perhaps  the  larger  proportion  of  cases,  more  especially 
those  in  which  the  joint  has  been  protected,  the  appearance  of 
the  abscess  is  not  preceded  by  acute  symptoms,  such  as  have  been 
described.  Its  appearance  is  long  delayed,  and  but  for  the 
swelling  its  presence  would  not  be  suspected. 

As  the  progress  of  the  disease  is  influenced  by  the  strain  and 
injury  to  which  the  part  is  subjected,  so  abscess,  a  symptom  of 
disease,  is  more  common  in  those  cases  in  which  early  and  effi- 
cient treatment  has  been  neglected ;  for  the  same  reason  its  sub- 
sequent course  is  directly  influenced  by  the  protection  that  the 
diseased  joint  receives. 

The  danger  from  abscess  is  infection.  Occasionally  the  ab- 
scess may  become  infected  before  an  opening  forms.  Such  in- 
fection may  be  inferred  when  the  overlying  tissues  are  hot  and 
sensitive,  and  when  fever  is  present ;  but,  as  a  rule,  the  abscess 
is  sterile  until  the  skin  is  perforated.  If  the  abscess  sac  is 
small  and  if  drainage  is  efficient,  and  especially  if  communica- 
tion with  the  joint  has  been  occluded,  infection  is  of  slight  con- 
sequence. But  if  before  the  opening  has  formed  the  abscess  has 
perforated  intermuscular  fascise  and  has  extended  between  the 
layers  of  muscles  in  various  directions,  infection  is  likely  to 
cause  severe  local  and  constitutional  symptoms.  The  thigh  be- 
comes the  seat  of  an  infectious  cellulitis,  pockets  of  pus  form, 
which  cannot  be  properly  drained;  hectic,  emaciation,  and  loss 
of  appetite  follow,  and  if  the  profuse  discharge  of  pus  persists 
amyloid  degeneration  of  the  internal  organs  may  result.  Such 
patients  are  said  to  die  of  exhaustion,  but  the  cause  of  exhaus- 
tion is  an  infected  abscess. 

Treatment. — Admitting  that  abscess  is  a  symptom  whose  im- 
portance stands  in  direct  relation  to  the  care  that  has  been 
exercised  in  the  treatment  of  the  disease,  and  that  in  the  better 
class  of  cases  the  danger  from  this  source  is  slight,  still  it  is  also 
true  that  abscess  is  the  chief  danger  in  hip  disease.  One's  views 
as  to  the  treatment  are  likely  to  be  influenced  by  the  class  of 
cases  with  which  he  is  most  familiar.  Some  surgeons  have 
advocated  absolute  non-interference  with  the  symptomatic  ab- 


390  ORTHOPEDIC  SUEGEBT. 

scess  on  the  gTound  that  in  many  instances  it  finally  disappears 
by  spontaneous  absorption,  or  that  the  communication  with  the 
joint  may  close,  so  that  the  danger  of  infection  after  an  opening 
has  formed  is  slight.  Finally,  that  the  results  after  non-inter- 
ference are  better  than  those  reported  after  operative  treatment. 
Others  insist  that  all  collections  of  fluid  of  this  character  should 
be  drained  as  soon  as  they  are  discovered,  because  of  the  danger 
of  infection  before  an  opening  forms  and  because  of  the  ad- 
vantage gained  by  preventing  burrowing  of  pus.  Little  could 
be  said  against  this  latter  course  were  it  not  that  infection  is  as 
common  after  operative  treatment  as  when  a  spontaneous  open- 
ing forms ;  the  only  advantage  in  favor  of  the  artificial  opening 
being  that  the  cavity  with  which  it  communicates  should  be 
smaller  and  more  direct  than  when  the  fluid  has  undermined  the 
tissues  in  various  directions,  but  this  is  offset  by  the  fact  that  at 
least  20  per  cent,  of  abscesses  disappear  without  treatment.  In 
fact,  as  compared  with  indiscriminate  incisions,  the  let-alone 
treatment  should  be  preferred  when  proper  after-treatment  can- 
not be  assured. 

It  would  appear,  however,  that  the  middle  course,  between 
the  extremes,  is  the  safest,  and  especially  so,  as  by  far  the  larger 
number  of  patients  must  be  treated  under  conditions  that  do  not 
permit  of  proper  care.  In  the  out-door  department  of  the  Hos- 
pital for  Ruptured  and  Crippled  abscesses  are  treated  symptom- 
atically.  If  a  swelling  appears  but  remains  quiescent  and  causes 
no  symptoms  it  is  not  disturbed.  If  it  enlarges,  the  tension  of 
the  fluid  is  relieved  by  aspiration,  which  may  be  repeated  as 
required,  compression,  after  the  evacuation  of  the  fluid,  being 
applied  by  means  of  a  pad  and  bandage.  If  the  contents  are  of 
such  a  nature  that  aspiration  is  unsatisfactory,  a  small  incision 
is  made,  the  contents  are  expressed  and  the  opening  is  imme- 
diately closed  with  sutures.  This  procedure  by  which  infection 
is  avoided  may  be  repeated  at  inteiTals.  It  may  be  employed 
also  when  deep-seated  abscess  within  the  joint  causes  painful 
tension. 

If  the  abscess  is  of  large  size,  or  if  acute  symptoms  are 
present,  the  child  is  admitted  to  the  hospital.  Here  the  same 
general  principle  is  followed,  but  in  certain  instances  it  may  be 
thought  advisable  to  explore  the  joint  in  addition  to  opening  the 
abscess.  In  such  cases  the  incision  must  be  longer,  the  wound 
is  then  closed  with  superficial  and  deep  sutures-,  and  a  firm 
dressing  is  applied.     This  operation,  if  performed  under  aseptic 


TUBEECULOUS  DISEASE  OF  THE  HIP-JOINT.  391 

precautions,  causes  no  disturbance,  and  it  removes  necrotic 
material  which  must  be  an  obstacle  to  spontaneous  absorption. 
In  many  instances  the  abscess  is  permanently  cured,  although 
if  the  condition  that  induced  it  remains  unchanged  fluid  will 
again  accumulate,  and  if  so  a  spontaneous  opening  will  form 
in  the  line  of  the  incision.  This  operation  is  not  a  radical  cure 
of  the  abscess  or  of  the  disease ;  it  is  simply  a  means  of  thorough 
evacuation  for  the  purpose  primarily  of  accomplishing  what 
the  aspirator  does  only  in  part.  If  the  abscess  has  become  in- 
fected its  contents  are  completely  removed,  the  wound  is  then 
packed  with  gauze,  and  provision  is  made  for  efficient  drainage. 

In  the  treatment  of  abscesses  the  injection  of  iodoform  emul- 
sion, in  connection  with  the  aspiration  or  incision,  has  been 
thoroughly  tested.  The  results,  as  far  as  the  disappearance  of 
the  abscess  was  concerned,  were  not  as  good  as  from  simple 
aspiration ;  and  as  the  procedure,  being  somewhat  of  the  nature 
of  an  operation,  caused  the  patients  some  discomfort  and 
anxiety,  it  was  discontinued.  From  the  clinical  standpoint 
there  is  little  evidence  that  these  injections  exercise  any  par- 
ticular influence  upon  the  disease,  but,  theoretically,  iodoform 
should  lessen  the  infectiousness  of  the  tuberculous  fluid,  and  by 
local  irritation  stimulate  the  growth  of  granulation  tissue.  (See 
Calot's  injection.) 

Sinuses.— Treatment.- — ^When  the  disease  is  active  the  sinuses 
that  serve  as  drains  should  not  be  disturbed.  And  in  the  ad- 
vanced cases  when  disease  is  quiescent  and  when  the  tissues 
about  the  joint  are  of  the  peculiar,  resistant,  "porky"  con- 
sistency, active  measures,  either  for  the  purpose  of  closing 
sinuses  or  for  the  correction  of  deformity,  should  be  deferred. 
In  many  instances,  however,  sinuses  persist  as  tuberculous 
flstulse,  serving  no  useful  purpose.  In  this  class  the  complete 
removal  of  the  infected  tissue  by  excision  or  by  thorough  curet- 
ting is  the  most  effective  remedy.  The  various  applications  of 
pure  carbolic  acid,  solution  of  salicylic  acid,  iodoform  emulsion, 
balsam  of  Peru,  and  the  like  are  of  some  service.  The  most 
satisfactory  supplemental  treatment  of  this  class  is  Beck's  mix- 
ture of  iodoform  and  vaseline — (1-3).  Sufficient  is  injected 
to  completely  fill  the  sinus  which  if  it  is  no  longer  necessary  as 
a  drain  often  closes,  the  mixture  being  gradually  absorbed,  other- 
wise the  injected  material  is  extruded. 

Exploratory  Operations. — In  certain  instances  exj)loratory 
operations  may  be  indicated.    If,  for  example,  pain  and  swelling 


392  OETHOPEDIC  SUBGEEY. 

indicate  tension  within  the  capsnle  it  may  be  relieved  by  a 
small  direct  incision  or  the  joint  may  be  explored  with  the 
possibility  of  finding  a  localized  focus  of  disease  that  may  be 
removed. 

The  joint  may  be  opened  by  an  anterolateral  incision,  begin- 
ning one  inch  to  the  outer  side  of  the  anterior  superior  spine  and 
extending  downward  about  three  inches.  This  exposes  the  line 
of  junction  between  the  tensor  vaginae  femoris  and  the  gluteus 
medius  muscles.  When  these  are  separated  from  one  another  the 
anterior  surface  of  the  capsule  of  the  joint  is  laid  bare.  If  more 
room  is  required  the  tensor  vaginae  femoris  muscle  may  be 
divided.  The  capsule  is  then  incised  in  the  line  of  the  neck  and 
through  the  incision  the  head  of  the  bone  may  be  extruded  by 
rotating  the  limb  outward  and  extending  it.  By  this  means  the 
character  of  the  disease  may  be  ascertained  and  in  certain  in- 
stances localized  foci  in  the  neck  or  in  the  head  of  the  bone  may 
be  removed.  The  wound  is  then  closed  or  drained  as  may  seem 
advisable.  By  such  intervention  the  course  of  the  disease  may 
be  shortened,  in  some  instances,  although  cure  by  this  means  is 
unusual. 

Temporary  anterior  dislocation  of  the  head  of  the  femur  by 
means  of  the  anterolateral  incision  may  be  of  value  in  acute  and 
painful  disease.  Posterior  dislocation  for  this  purpose  has  been 
performed  by  Bradford  in  several  cases  with  satisfactory  results, 
the  bone  being  again  replaced  when  the  disease  had  become  qui- 
escent.-^ The  object  of  this  operation  is  to  remove  the  apposing 
bones  from  direct  contact,  and  to  relieve  the  muscular  spasm 
that  accompanies  acute  disease. 

Exploratory  operations  may  be  of  special  value  in  the  later 
stages  of  the  disease,  to  ascertain  the  cause  of  long-continued 
suppuration,  or  of  abnormal  delay  in  repair,  which  may  be  due 
to  detached  or  adherent  fragments  of  necrosed  bone  within  the 
joint.  This  point  is  illustrated  by  the  statistics  of  61  cases  of 
hip  disease. treated  by  excision  by  Poor.^  In  15  of  these  loose 
bone  was  found  in  the  joint,  and  in  7  the  head  of  the  bone  was 
detached. 

In  98  cases  investigated  by  Lehman-'  at  the  Wiirzburg  clinic 
sequestra  were  present  in  20.4  per  cent.,  and  in  70  per  cent,  of 
88  cases  treated  by  Riedel.'* 

^  Transactions  of  the  American  Ortliopedic  Association,  vol.  xiii. 

=  New  York  Medical  Journal,  April  23,  1892. 

^  Inaug.  Diss.  Wurzburg,  1896. 

*  Centralbl.  f.  Chir.,  1893,  Bd.  xx.,  Nos.  7  and  8. 


TUBERCULOUS  DISEASE  OF  TEE  HIP-JOINT.  393 

An  exploration  of  the  joint  by  one  familiar  with  surgical 
technique  should  be  free  from  danger,  and  it  may  be  of  much 
value. 

Excision  of  the  Hip. — The  operation  of  excision  is  now 
classed  as  a  treatment  of  necessity  in  certain  cases,  usually  those 
in  which  recovery  under  conservative  treatment  is  considered 
very  doubtful.  For  example,  when  there  is  progressive  failure 
of  health;  when  it  is  impossible  to  drain  the  joint  effectively 
after  infection ;  when  there  is  evidence  of  extension  of  the  dis- 
ease to  the  shaft  of  the  femur  or  to  the  pelvic  cavity,  or  when 
other  serious  complications  exist. 

In  certain  instances  the  excision  may  follow  an  exploratory 
operation ;  in  such  cases  the  anterolateral  incision  may  be  em- 
ployed and  the  neck  and  head  of  the  bone  only  may  be  removed. 
In  this  operation  the  diseased  tissue  is  removed  as  thoroughly  as 
possible  with  the  sharp  spoon,  by  scrubbing  with  iodoformized 
gauze,  and  by  flushing  with  hot  water.  If  the  joint  is  not  in- 
fected it  is  dried;  iodoform  emulsion  may  be  injected  or  the 
pure  carbolic  acid  may  be  applied,  and  the  various  tissues  are 
then  sewed  in  layers ;  pressure  is  applied,  the  aim  being  to  secure 
immediate  union.  If  this  does  not  take  place  drainage  is  em- 
ployed in  the  usual  manner. 

In  typical  cases  the  operation  is  performed  because  of  exten- 
sive disease  and  infected  abscess,  and  in  such  instances  usually 
the  entire  upper  extremity  of  the  bone  to  the  trochanter  minor 
is  removed. 

A  satisfactory  method  is  that  of  Koenig. 

An  incision  about  five  inches  in  length  is  made  in  a  line  join- 
ing the  trochanter  and  the  posterior  inferior  spine  of  the  ilium. 
About  two-thirds  of  the  length  is  above  and  one-third  over  the 
trochanter.  The  incision  is  deepened  to  expose  the  capsule  and 
the  surface  of  the  trochanter,  from  which  one  removes  the  inser- 
tion of  the  gluteus  maximus  and  the  tendons  of  the  medius  and 
minimus.  The  muscles  are  separated  in  the  line  of  the  incision 
and  the  capsule  is  widely  opened.  With  a  thick,  strong  knife 
one  detaches  all  the  muscular  attachments  to  the  anterior  margin 
of  the  trochanter,  while  the  limb  is  rotated  outward,  removing, 
if  possible,  a  thin  section  of  periosteum  and  bone.  The  same 
process  is  then  repeated  on  the  posterior  surface,  the  limb  being 
rotated  inward.    The  trochanter  is  then  removed. 

The  acetabular  insertion  of  the  capsule,  together  with  the 
adjoining  upper  border  of  the  acetabulum,  is  then  cut  away  and 


394 


OETHOPEDIC  SUEGEBY. 


the  neck  of  the  femur  is  separated  from  the  shaft  with  a  saw 
or  chisel.  All  the  diseased  parts  are  then  removed,  including 
the  acetabular  wall  and  adjoining  bone,  if  necessary.  The 
wound  is  partly  closed  with  drainage,  and  the  extremity  of  the 
femur  is  placed  within  the  acetabulum,  where  it  should  be 
retained  for  a  time  by  a  plaster  bandage  or  Thomas  brace  pro- 
vided with  traction  straps.  When  the  patient  begins  to  walk  a 
hip  splint  or  other  support  is  used  for  a  time  to  prevent  de- 
formity. One  of  the  most  efficient  supports  of  this  class  is  the 
short  spica,  the  limb  being  fixed  in  an  attitude  of  overextension 
and  moderate  abduction  for  many  months  with  the  aim  of  ob- 
taining bony  or  fibrous  anchylosis. 

Another  form  of  incision  is  that  of  Rydygier^  shown  in  the 
accompanying  illustration.  The  flap  is  lifted,  the  trochanter 
major  is  cut  through  and  with  its  attached  muscles  turned  up- 

FiG.  282. 


Rydygier's  incision  for  excision  of  the  hip. 


ward.  The  capsule  is  then  opened  and  the  femur  is  dislocated 
for  inspection.  All  the  diseased  parts,  including  the  entire 
acetabulum,  if  necessary,  together  with  the  capsule,  are  then 
removed.  Complete  removal  of  the  acetabulum  is  indicated 
when  it  is  perforated,  a  procedure  particularly  advocated  by 
Bardenheuer. 

The  success  or  failure  of  excision  of  the  hip  as  a  life-saving 
operation,  provided  the  diseased  bone  has  been  removed,  is  de- 
^  Mosetig-Moorhof ,  Wiener  klin.  Wochen.,  No.  20,  1905. 


TUBEBCULOUS  DISEASE  OF  THE  EIP-JOINT.  395 

cided  bj  the  after-treatment,  and  in  this,  drainage  is  the  first 
essential.  The  opening  must  be  large  and  the  shaft  of- the  bone 
must  be  drawn  down  by  efficient  traction,  so  that  it  may  not 
obstruct  the  opening,  and  the  exuberant  granulations  must  be 
removed  from  time  to  time.  Short  glass  drainage  tubes  of 
diameter  up  to  one  and  one-half  inches  as  suggested  by  Phelps 
may  be  used  with  advantage.  Through  such  a  tube  or  speculum 
the  gauze  is  inserted,  the  opening  permitting  inspection. 

The  importance  of  an  open-air  life  after  these  operations  can 
hardly  be  exaggerated.  The  lack  of  this,  the  inefficiency  of  the 
after-treatment  in  securing  proper  drainage,  and  the  postpone- 
ment of  the  operation  until  amyloid  changes  are  advanced  ex- 
plain the  unsatisfactory  character  of  the  results. 

The  functional  results  after  excision  in  this  class  of  cases  are 
not  as  good  as  those  that  may  be  obtained  when  the  operation 
has  been  performed  at  an  earlier  period.  If  motion  continues 
free  there  is  usually  a  corresponding  weakness  of  weight-bearing 
function.  In  many  instances  there  is  upward  displacement  of 
the  shaft  of  the  femur  upon  the  ilium  with  consequent  flexion 
.and  adduction  deformity,  while  in  a  third  class  of  cases  a  mov- 
able joint  of  sufficient  strength  may  be  preserved.  The  ultimate 
shortening  is  considerably  greater  than  after  conservative  treat- 
ment. This  is  accounted  for  the  upward  displacement  of  the 
femur  and  by  the  removal  of  the  two  epiphyses  of  its  upper 
extremity. 

In  a  period  of  twelve  years,  1888  to  1899,  inclusive,  149 
operations  of  excision  were  performed  at  the  Hospital  for  Rup- 
tured and  Crippled.  During  this  time  1283  cases  of  hip  disease 
were  treated  in  the  wards  and  1870  new  cases  were  recorded  in 
the  out-patient  department.  Thus  the  operation  was  performed 
in  11.6  per  cent,  of  those  in  the  hospital,  but  the  relative  fre- 
quency of  the  operation  in  the  entire  number  of  patients  under 
treatment  was  considerably  less  than  this. 

One  hundred  and  twenty-one  of  these  operations  of  excision, 
or  those  performed  prior  to  1897,  have  been  carefully  analyzed 
by  Townsend.^  The  121  operations  were  performed  on  119 
patients,  in  two  instances  both  hips  having  been  operated  upon. 
In  113  abscesses  or  sinuses  were  present,  in  most  instances  in- 
fected. In  5  cases  there  was  disease  of  the  spine  as  well  as  the 
hip ;  in  2  instances  of  the  knee ;  in  2  of  the  tarsus ;  in  3  of  the 
ilium.     In  24  the  anterior  incision  was  employed,  in  97  the 

^  Medical  News,  June  26,  1897. 


396  OBTHOPEDIC  SUE GEE Y. 

posterior.  In  18  instances  the  acetabulum  was  seriously  dis- 
eased, and  in  10  the  shaft  of  the  femur  was  involved.  This 
indicates  the  character  of  the  disease  in  the  cases  operated  upon. 

In  99  of  the  119  cases  the  later  results  of  the  operation  were 
ascertained.  Of  these  53  were  dead  and  47  were  living.  Of  the 
52  deaths  9  were  due  directly  to  the  operation,  ''shock'";  28 
were  caused  by  exhaustion  (persistent  suppuration)  ;  9  by  tuber- 
culous meningitis ;  7  by  other  causes.  Thirty-seven  deaths  oc- 
curred within  six  months  and  10  others  within  one  year  of  the 
operation.  Of  the  47  patients  living  at  the  time  of  the  investi- 
gation, 26  were  cured.  Of  the  remaining  number  about  one- 
half  were  in  poor  condition,  so  that  recovery  could  not  be  ex- 
pected. It  is  evident  that  in  a  large  proportion  of  the  cases  the 
operation  was  unsuccessful  as  a  life-saving  measure,  since  sup- 
puration persisted.  The  functional  results  in  these  cases  are 
shown  in  the  table  on  the  following  page : 

Lovett^  has  reported  the  results  of  50  excisions  in  a  similar 
class  of  cases  at  the  Boston  Children's  Hospital,  1877  to  1895. 
The  number  of  patients  actually  treated  in  the  wards  of  the  hos- 
pital is  not  stated,  but  1100  cases  were  recorded  as  having  been 
under  treatment  during  this  time,  a  percentage  of  excisions  of 
4.5  of  the  total  number.  In  8  of  the  cases  osteomyelitis  of  the 
femur  was  present,  and  in  15  the  acetabulum  was  perforated. 
The  ultimate  mortality  was  about  50  per  cent. 

Poor^  has  reported  the  results  in  65  cases  operated  upon  at 
St.  Mary's  Hospital,  i^ew  York,  with  a  final  mortality  of  about 
34  per  cent.  In  21  cases  osteomyelitis  of  the  shaft  of  the  femur 
was  present.  In  11  cases  there  was  perforation  of  the  acetabu- 
lum, and  in  9  of  these  the  opening  communicated  with  an  intra- 
pelvic  abscess. 

These  statistics  are  quoted  to  illustrate  the  relative  efficiency 
of  late  excision.  The  extent  of  the  lesions  in  some  of  the  cases 
shows  that  recovery  would  have  heen  impossible  without  opera- 
tion, and  its  failure  to  relieve  the  symptoms  in  so  many  instances 
is  sufficient  evidence  that  it  was  postponed  too  long  or  that  it 
was  not  sufficiently  radical.  Under  proper  conditions  for  treat- 
ment excision  of  the  hip  is  almost  never  required,  but  in  hospital 
practice  it  should  be  performed  oftener  and  earlier  in  the  course 
of  the  disease. 

Amputation. — Amputation  at  the  hip  should  follow  excision 

^  Transactions  American  Orthopedic  Association,  vol.  x. 
=  New  York  Medical  Journal,  April  23,  1892. 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


397 


if  suppuration  persists  and  if  the  condition  of  the  patient  does 
not  improve,  provided  the  internal  organs  are  not  hopelessly 
diseased.  The  operation  of  amputation  after  complete  excision 
is  a  simple  procedure  and  it  should  not  be  attended  with  great 
danger. 


Table  Showing  Shortening,  Motion,  Number  of  Sinuses  Present,  and 
Angle  of  Greatest  Extension   in  Forty-seven   Cases  op  Ex- 
cision.     (TOWNSEND.) 


Time  since 

General 

Sinuses 

Angle  of 

Motion  in 

Shortening 
in  inches. 

No. 

operation. 

condition. 

present. 

greatest 
extension. 

degrees. 

1 

61  years 

Good 

3 

150 

0 

2* 

2 

6i     " 

Fair 

1 

135 

0 

4" 

3 

6       " 

Good 

0 

180 

100 

3 

4 

of     " 

a 

0 

180 

35 

3 

5 

5f     - 

Fair 

0 

145 

10 

4 

6 

5J     " 

Good 

1 

165 

0 

li 

7 

5       " 

li 

0 

155 

5 

^ 

8 

4|     " 

a 

3 

160 

0 

^ 

y 

4*     " 

" 

0 

160 

0 

2| 

10 

4  " 

u 

0 

165 

0 

H 

11 

4       " 

u 

0 

1.50 

0 

1* 

12 

4       " 

Poor 

4 

0 

ll 
1? 

13 

3J     " 

Good 

0 

155 

0 

14 

3i     " 

11 

0 

160 

30 

1 

15 

3       " 

Poor 

1 

165 

0 

f 

16 

2       " 

Fair 

2 

145 

30 

4: 

17 

2       " 

Good 

^ 

18 

2       " 

Fair 

1 

170 

0 

i 

3 

19 

2       " 

Good 

0 

150 

0 

20 

^4 

(( 

0 

175 

i 

21 

13         U 

li 

0 

165 

"36 

i 

22 

n   " 

11 

0 

150 

0 

1 

23 

i  i 

0 

150 

0 

U 

24 

H    " 

a 

1 

180 

0 

I 

25 

u  ;; 

Fair 

6 

175 

15 

1 

26 

Poor 

2 

165 

0 

2J 

27 

Good 

0 

170 

0 

U 

28 

(( 

0 

J  55 

0 

1 

29 

11 

0 

175 

0 

i 

30 

Poor 

0 

180 

10 

u 

31 

11  months 

u 

3 

170 

0 

1 

32 

10       " 

a 

0 

180 

40 

l{ 

33 

10       " 

Good 

3 

165 

0 

^ 

34 

10       " 

ii 

0 

160 

0 

1 

2 

35 

10       " 

a 

1 

165 

0 

1 

36 

10       " 

Poor 

1 

160 

0 

X 

37 

10       " 

Good 

3 

155 

10 

li 

38 

9       " 

(t 

1 

0 

^ 

39 

9       " 

(1 

0 

...„ 

i 

40 

9       " 

Poor 

1 

170 

i 

41 

9       " 

Fair 

3 

1 

42 

8       " 

Good 

0 

180 

130 

* 

43 

8      " 

" 

0 

180 

i 

44 

8       " 

Poor 

1 

165 

'10 

f 

45 

7       " 

i  I 

46 

7       " 

Good 

0 

180 

10 

11 

47 

7       " 

a 

0 

160 

70 

I- 

398 


OBTHOPEDIC  SUBGEBY. 


Correction  of  Deformity.— The  various  .methods  of  correct- 
ing deformity  during  the  active  stages  of  the  disease  have  been 
described,  and  the  importance  of  preventing  deformity  through- 
out the  entire  course  of  treatment  has  been  emphasized.  At 
the  present  time,  for  one  reason  or  another,  deformity  from 
this  cause  is  very  common,  either  because  its  importance  is  not 
appreciated  or  because  it  is  considered  as  a  necessary  con- 
comitant of  the  disease,  treated  by  apparatus,  as  it  is  in  the 
natural  cure.  At  all  events,  in  many  instances  it  is  allowed  to 
persist  until  the  accommodative  changes  about  the  diseased  joint 
have  fixed  the  limb  in  the  deformed  position. 

In  this  class  of  cases,  in  which  the  muscles  are  structurally 
shortened   and  in  part  transformed  to  fibrous  tissue,   and  in 

Fig.  283. 


Extreme  deformity  after  hip  disease,  showing  the  attitude  before  operation. 
(See  Figs.  284  and  285.) 


which  the  anterior  wall  of  the  capsule  has  become  retracted  and 
adherent  to  the   surrounding  parts,   forcible   reduction   under 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


399 


ansesthesia,  or  osteotomy,  may  be  required.  If  the  disease  is 
quiescent  or  cured,  if  the  head  of  the  femur  or  what  remains  of 
it  is  in  the  normal  position,  and  if  a  fair  range  of  motion  re- 
mains, forcible  reduction  after  division  of  the  bands  of  fascia  or 
the  muscles  that  hold  the  limb  in  the  deformed  position  is 
advisable. 

In  all  cases  in  which  the  head  of  the  bone  is  destroyed,  motion 
persisting  (pathological  excision),  the  aim  should  be  to  secure 
an  anterior  transposition  of  the  upper  extremity  of  the  femur, 
and  to  secure  this  result  one  proceeds  as  in  reducing  or  transpos- 
ing the  congenitally  displaced  hip — by  longitudinal  traction,  by 
forcible  abduction,  combined  with  massage  of  the  adductors, 
.and,  finally,  by  gradual  extension — preceded  usually  by  division 
of  the  resistant  parts  about  the  anterior  superior  spine.  The 
limb  is  then  fixed  by  a  plaster  spica  in  an  attitude  of  moderate 
abduction  and  overextension.  Later  the  abduction  is  lessened, 
but  the  overextended  position  is  maintained  for  many  months, 
and  is  assured  by  passive  movements  after  the  support  is  re- 
moved. Forcible  reduction  in  cured  or  quiescent  cases  is  prac- 
tically free  from  danger. 

Femoral  Osteotomy.- — If  the  deformity  is  fixed  by  bony  anchy- 
losis or  by  firm,  fibrous  adhesions  within  the  joint;  or  if  it  is 
feared  that  violence  may  stimulate  dormant  disease ;  or  if  there 
is  such  a  degree  of  upward  displacement  of  the  femur  upon  the 
pelvis  that  the  deformity  is  likely  to  recur  after  replacement,  it 
is  better  to  correct  the  deformity  by  an  osteotomy  of  the  femur. 

Fig.  284. 


The  favorite  attitude  in  recumbency.       (See  Fig.   283.) 


The  patient  having  been  prepared  for  operation,  is  turned 
upon  the  side  and  a  sand-bag  is  placed  between  the  thighs.  A 
small  osteotome,  about  the  shape  of  a  lead-pencil,  of  which  one 
extremity  is  flattened  to  a  cutting  edge   (Vance's  instrument), 


400 


ORTHOPEDIC  SUEGEEY. 


Fig.  285. 


is  pushed  directly  through  the  soft  parts  to  the  femur  at  a  point 
about  two  inches  below  the  apex  of  the  trochanter.  It  is  turned 
until  its  cutting  edge  is  at  the  right  angle  to  the  shaft  and  it  is 
then  driven  through  the  cortical  substance  of  the  bone.  When 
it  has  penetrated  at  one  point  it  is  withdrawn,  and  adjoining 

portions  are  cut  until  about  half  the  cir- 
cumference is  divided,  when  with  slight 
force  the  bone  may  be  fractured.  If 
the  deformity  is  of  long  standing,  divi- 
sion of  the  contracted  tissues  in  the  ad- 
ductor region  and  below  the  anterior 
superior  spine  may  be  required. 

The  advantages  of  the  subcutaneous 
plete  extension  and  moderate  abduction, 
and  the  body  and  limb  are  encased  in  a 
plaster-of-Paris  spica  bandage,  which 
should  remain  in  position  for  several 
months,  although  the  patient  may  be 
allowed  to  bear  weight  on  the  limb  a 
few  weeks  after  the  operation.  The 
long  may  be  replaced  by  the  short  spica 
at  the  end  of  two  months.  The  latter 
or  some  similar  appliance  should  be 
used  until  tests  show  that  there  is  no 
longer  danger  of  recurrence  of  the  de- 
formity. 

The  advantages  of  the  subcutaneous 
method  are  simplicity  and  freedom  from 
danger.  'No  dressings  are  required,  ex- 
cept a  pad  of  gauze  over  the  minute 
opening;  thus  the  limb  may  be  firmly 
held  by  the  plaster  bandage.  If  there  is 
anchylosis  between  the  femur  and  the 
otomy  and  division  of  tiic   pelvis  uo  support  will  be  required  after 

contracted  tissues     (Gibney.)     ^^^^    |^  ^  ^^-^^^1      ^^^^     -f    ^^^^,^     -^ 

(See  Ligs.  283  and  284.)  _  _  _    _         ' 

motion  in  the  joint  some  fixative  ap- 
pliance should  be  employed  for  a  time  to  prevent  recurrence  of 
a  part  of  the  deformity.  In  cases  in  which  motion  is  preserved, 
and  yet  because  of  depression  or  shorteuiiig  of  the  femoral  neck 
abduction  is  checked  by  contact  of  the  trochanter  with  the  pelvis 
cuneiform  osteotomy  as  described  in  the  treatment  of  Coxa 
vara  shrjuld  be  performed  (Fig.  286). 


After    correction    by    oste 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT. 


401 


Prognosis. Mortality The  direct  mortality  of  hip  disease 

is  due  almost  entirely  to  the  immediate  or  remote  effects  of  ab- 
scess.    This  is  illustrated  by  the  statistics  of  Bruns,  in  which 


Fig.  286. 


The  correction  cf  adduction  deformity  by  cuneiform  osteotomy. 

the  mortality  from  all  causes  of  the  non-suppurative  cases  was 
23' per  cent,  as  compared  with  52  per  cent,  in  those  in  whom 
suppuration  was  present. 

The  mortality  among  the  patients  treated  at  many  of  the 
German  clinics  is  much  higher  than  in  the  corresponding  class 
in  this  country. 

At  Tubingen,  according  to  Wagner/  it  was  40  per  cent. 

At  Kiel,  according  to  Mummelthy,  it  was  48.59  per  cent,  in 
non-operative  cases  and  53.96  per  cent,  in  operative  cases. 

At  Marburg,  according  to  Marsch,  it  was  35  per  cent,  in  non- 
operative  cases  and  40.4  per  cent,  in  operative  cases. 

At  Heidelberg,  according  to  Huismans,^  it  was  46.6  per  cent. 

in  non-operative  cases  and  58  per  cent,  in  operative  cases. 

^Beit.  z.  klin.  Chir.,  1895,  Bd.  xiii. 

2  Quoted  by  Binder,  Zeits.  f .  Orthop.  Chir.,  1889,  Bd.  vii.,  H.  2  und  3. 

26 


402  OETHOPEDIC   SFEGESY. 

At  Ziiricli.  according  to  Pedolin/  it  was  37.7  per  cent,  in  non- 
oj)erative  cases  and  54  per  cent,  in  operative  cases. 

At  Vienna,  according  to  Prendlsbnrger,-  it  was  17  per  cent. 
in  all  cases. 

At  Gottingen.  according  to  Koenig,^  40.3  per  cent. 

Dolliuger^  estimates  the  mortalitv  from  all  causes  in  German 
clinics  as  48.8  per  cent.  In  non-su23purative  cases  as  16.5  per 
cent. 

In  a  total  of  636  cases  treated  bv  conservative  methods  bv 
Rabl.  1S59  to  1S94.  definite  results  were  ascertained  in  519;^ 
335  were  hospital  cases.  Of  these  216  were  cured,  64.4  per 
cent.;  70  died.  20.8  per  cent.,  and  49.  14.4  per  cent.,  were  still 
under  treatment:  1S4  were  treated  as  out-patients.  Of  these, 
132  were  cured,  71.5  per  cent.;  35  died,  19.2  per  cent.,  and  17, 
9.2  per  cent.,  remained  under  treatment. 

Menard*^  in  a  series  of  1321  cases  treated  under  favorable 
conditions  estimates  the  mortality  at  7  per  cent. 

In  288  cases  treated  at  the  Hospital  for  Euptured  and  Crip- 
pled, Xew  York,  reported  by  Gibney,'  the  death-rate  was  12.5 
per  cent. 

In  93  final  results  of  cases  treated  at  the  Boston  Children's 
Hospital  there  were  6  deaths,  6.4  per  cent.^ 

In  private  practice  the  statistical  reports  of  final  results  show 
the  death-rate  to  be  extremely  small.  C.  F.  Taylor,®  94  cases, 
including  24  in  which  suppuration  was  present,  3  deaths.  L. 
A.  Sayre,^'-*  212  cases,  5  deaths.  Lorenz.^^  60  cases,  with  3 
deaths. 

In  the  clinics  of  this  country  the  death-rate  has  been  esti- 
mated to  be  from  10  to  15  per  cent.,  a  rate  of  mortality  much 
lower  than  that  reported  from  those  abroad.  This  is  accounted 
for  in  part  by  the  fact  that  patients  are  of  a  better  class  and  in 
part  because  they  receive  earlier  and  more  eflieient  mechanical 
protection. 

'  Centralbl.  f.  Chir..  .July  25.  1S9(5.  Xo.  30. 
-  Loe.    cit. 

^  Koenig,  Das  Hoeftgelenk.  Berlin.  1902. 
'  Handb.  d.  Orth.  Chir..  1906. 

'  Ziir  Conserv.  Behand.  der  tuberculosen  Knochen  und  Gelenksleiden,  J. 
Eabl,  Leipzig  und  Wien,  1895. 
'  Etude  sur  Coxalgie,  1907. 

'Xew  York  Medical  .Journal.  .July  and  August,  1S77. 
*  Bradford,  loe.  cit. 

'Boston  Medical  and  Surgical  .Journal.  March  6,  1879. 
"Xew  York  Medical  .Journal.  April  30.  1892. 
^'Wiener  Klinik.  1892.  10  and  11. 


TUBEBCULOUS  DISEASE  OF  THE  HIP-JOINT.  403 

The  causes  of  death,  according  to  Wagner's  statistics  of  124 
cases,  were  as  follows : 

Hip    disease 35 

General  tuberculosis    37 

Tuberculous   meningitis    13 

Tuberculosis  of  the  lungs 11 

Acute  miliary   tuberculosis 5 

Amyloid    degeneration    8 

Septic  infection   12 

Intercurrent  disease    3 

124* 

Thirty  per  cent,  of  the  deaths  occurred  in  the  first  year  of  the 
disease,  26  per  cent,  in  the  second  year,  and  20.4  per  cent,  in 
the  third  year. 

The  percentage  of  recovery  was  65  per  cent,  of  those  in  the 
first  decade  of  life,  56  per  cent,  of  those  in  the  second,  and  but 
28  per  cent,  of  those  in  the  third  decade. 

The  causes  of  death  in  50  cases  among  7Y8  patients  treated 
at  the  iSTew  York  Orthopedic  Dispensary  and  Hospital  during 
the  years  1877  to  1882  were:^ 

Tuberculous   meningitis    20 

Amyloid  degeneration 5 

Exhaustion    3 

Tuberculosis  of  the  lungs   3 

Tuberculous   peritonitis    1 

SepticEemia    1 

Convulsions   1 

Unknown    16 

50 

Of  96  deaths  recorded  at  the  Alexandra  Hospital,  London  (a 
mortality  of  about  26  per  cent,  of  the  cases  treated),  the  causes 
were : 

Tuberculous  meningitis   16.1  per  cent. 

Albuminuria   and   dropsy 20.8  per  cent. 

Tuberculosis  of  the  lungs 8.3  per  cent. 

Exhaustion   9.4  per  cent. 

Erysipelas  and  pyasmia   3.1  per  cent. 

After   operation    9.4  per  cent. 

Intercurrent   diseases    7.3  per  cent. 

Unknown     25.0  per  cent. 

100.0  per  cent. 

The  direct  mortality  of  hip  disease  should  include  all  deaths 
due  to  operation,  those  caused  by  exhaustion,  and  amyloid  de- 
generation, which  is  almost  always  the  result  of  profuse  suppura- 
tion secondary  to  pyogenic  infection.     Tuberculous  meningitis, 
'  Shaffer  and  Lovett,  New  York  Medical  Journal,  May  21,  1887. 


404  OSTHOPEDIC  SUBGEBY. 

a  common  and  apparently  an  unavoidable  canse  of  death,  is  not 
necessarily  a  complication  of  the  local  disease,  except  in  so  far  as 
a  lowered  vitality  may  predispose  the  patient  to  it,  since  it  may 
have  been  due  to  new  infection  or  induced  by  the  primary  focus 
which  preceded  the  tuberculosis  of  the  hip. 

It  is  believed  that  operative  interference  is  sometimes  the 
direct  cause  of  tuberculous  meningitis,  and  it  is  of  interest  in 
this  connection  to  note  that  20  of  50  deaths,  or,  rather  of  34,  in 
which  the  cause  of  death  was  known  (58  per  cent.),  were  due 
to  this  complication  among  the  cases  treated  at  the  iN'ew  York 
Orthopedic  Dispensary  and  Hospital,  where  no  operations  were 
performed.^  While  of  52  deaths  in  a  total  of  99  cases  treated  at 
the  Hospital  for  Ruptured  and  Crippled,  in  which  excision  was 
performed,  but  9  were  caused  by  tuberculous  meningitis.^ 

The  normal  death-rate  among  cases  under  fair  hygienic  con- 
ditions is  illustrated  by  statistics  from  the  Hospital  for  Rup- 
tured and  Crippled  at  a  time  when  no  operative  or  mechanical 
treatment  was  employed.^  This  was  12.5  per  cent. ;  4.5  per  cent, 
from  exhaustion,  4.5  per  cent,  from  amyloid  degeneration,  1.75 
per  cent,  from  tuberculous  meningitis,  1.75  per  cent,  from  inter- 
current diseases. 

Thus  nearly  75  per  cent,  of  the  deaths  were  due  more  or  less 
directly  to  suppuration. 

Functional  Results.. — In  a  certain  proportion  of  cases  perfect 
function  may  be  retained,  the  proportion  depending  upon  the 
accuracy  of  diagnosis  in  excluding  mild  types  of  arthritis  which 
are  often  mistaken  for  tuberculous  disease ;  upon  the  situation 
and  the  extent  of  the  disease,  and  upon  the  timeliness  and  effi- 
ciency of  the  treatment. 

Recovery  with  perfect  function  which  implies  a  normal  joint 
and  therefore  a  limited  area  of  disease  is  not  a  test  of  relative 
efficiency  of  mechanical  treatment  since  approximately  the  same 
result  might  be  attained  by  any  form  of  adequate  protection. 

In  a  total  of  280  cases  from  the  private  practice  of  Dr.  L.  A. 

Sayre,*  in  which  the  final  results  were  known,  73,  or  26  per 

cent.,  recovered  with  perfect  motion,  and  120  or  42  per  cent., 

retained  good  motion.     These  results  are  extraordinarily  good, 

very  much  better  than  any  others  that  have  been  reported,  and, 

of  course,  far  better  than  may  be  expected  in  the  ordinary  class 

of  cases. 

^  Ibid. 

-  Townsend,  Medical  News,  June  26,  1896. 

=  Gibney,  New  York  Medical  Record,  March  2,  1878. 

'New  York  Medical  Journal,  April  30.  1892. 


TUBEBCULOUS  DISEASE  OF  THE  EIP-JOINT.  405 

In  a  series  of  51  cases  illustrating  final  results  of  treatment 
at  the  Boston  Children's  Hospital,  there  was  practical  fixation 
at  the  joint  in  33,  60  per  cent.  In  16  perfect  motion  was  re- 
tained. Adduction  was  present  in  21,  40  per  cent.  The  tro- 
chanter was  above  JSTeleton's  line  in  19,  37  per  cent.^ 

In  35  final  results  treated  by  the  traction  hip  splint  at  the 
ISTew  York  Orthopedic  Dispensary  practical  fixation  was  present 
in  74  per  cent,  of  the  patients.^ 

The  effect  of  mechanical  treatment  and  of  the  various  meas- 
ures employed  for  the  correction  of  deformity  is  well  illustrated 
in  two  series  of  ultimate  results  in  cases  treated  at  the  Hospital 
for  Euptured  and  Crippled,  reported  by  Gibney.^  In  the  first 
series  of  80  cases  no  mechanical  or  operative  measures  were 
employed,  the  treatment  being  simply  hygienic  and  sympto- 
matic ;  the  results,  therefore,  represent  natural  cure  under  super- 
vision. The  duration  of  the  disease  was  three  years  in  23 ; 
three  to  six  years  in  28 ;  six  to  ten  years  in  16,  and  fifteen  years 
in  one  case. 

In  35  cases  the  shortening  was  two  inches  or  more,  and  in 
nearly  every  case  there  was  more  or  less  deformity,  viz. : 

In  2  there  was  flexion  to 90° 

Tn  3  there  was  flexion  to 110 

In  3  there  was  flexion  to 120 

In  19  there  was  flexion  to 135 

In  19  there  was  flexion  to 145 

In  18  there  was  flexion  to 150 

In  11  there  was  flexion  to 160-170 

In  4  no  estimate  was  made.  Distortions  other  than  flexion 
are  not  specified. 

In  12  instances  motion  was  retained  of  from  15  to  90  degrees. 

No   flexion    47 

Flexion  of  10°   30 

Flexion  of  10-20°   20 

Flexion   of   20-30°    10 

Perfect  motion  was  retained  in 13 

Good  motion  was  retained  in 22 

Limited  motion  was  retained  in '.  . .  .  41 

There  was  anchylosis  in   31 

In  the  second  series^  of  107  cured  cases,  mechanical  and 
operative    treatment    was    employed,    although    the    protection 

^  Bradford  and  Soutter,  loc.  cit. 
^Loc.  cit. 
^  Loc.  cit. 

^  Gibney,  Waterman,  and  Eeynolds,  Trans.  Amer.  Orth.  Assoc,  1898,. 
vol.  xi. 


406  OETEOPEDIC  SUEGEBY: 

assured  was  in  many  instances  far  from  efficient.  In  many  of 
these  cases  tlie  disease  was  in  an  advanced  stage,  and  deformity 
was  present  in  more  than  half  of  the  number  when  treatment 
was  begun,  and  yet  all  of  them  recovered  without  marked  flexion 
and  presumably  without  adduction,  as  this  deformity  is  not 
mentioned. 

In  69  cases  the  shortening  was  one  inch  or  less,  35  having  no 
shortening.     In  38  it  was  more  than  one  inch. 

As  has  been  stated,  the  mechanical  treatment  in  these  cases 
was  not  sufficiently  efl^ective  to  prevent  deformity,  and  to  attain 
these  results  osteotomy  with  or  without  division  of  contracted 
tissues  was  performed  in  19  cases,  forcible  correction  with  or 
without  tenotomy  in  30  cases,  and  in  4  cases  the  joint  was 
excised. 

If  the  joint  has  been  actually  invaded  by  disease  so  that  a 
part  of  its  articulating  surface  has  been  destroyed,  motion  must 
be  impeded  both  in  area  and  quality.  In  such  cases  the  joint  is 
somewhat  weakened,  and  it  is  often  sensitive,  although  in  many 
instances  not  to  the  extent  of  interfering  seriously  with  the 
ability  of  the  patient.  In  this  class  discomfort  in  damp  weather 
or  pain  on  overexertion  is  experienced,  symptoms  similar  to 
those  complained  of  by  rheumatic  subjects.  Absolute  anchylosis 
is  therefore  a  far  more  satisfactory  result  in  patients  of  the 
laboring  class. 

Simple  shortening,  due  to  retardation  of  growth,  unaccom- 
panied by  deformity,  is  of  comparatively  little  importance.  Firm 
anchylosis  in  a  symmetrical  position  ensures  a  strong  and  useful 
limb,  the  flexibility  of  the  lumbar  region  compensating  for  the 
loss  of  motion  at  the  joint.  In  such  cases  the  disability  may 
be  very  slight,  and  the  effect  of  the  loss  of  motion  may  be  more 
apparent  in  the  sitting  than  in  the  erect  posture,  for  the  patient 
must,  as  it  were,  sit  upon  his  back,  an  attitude  which  perceptibly 
reduces  the  sitting  height. 

Flexion,  if  of  moderate  degree,  does  not  cause  disability,  but 
flexion  of  more  than  30  degrees  increases  the  lumbar  lordosis 
and  makes  the  buttock  prominent,  the  deformity  so  character- 
istic of  the  natural  cure  (Fig.  219).  Great  flexion,  for  example, 
of  60  or  90  degrees,  causes  an  exaggerated  lordosis  which  is 
almost  always  a  source  of  pain  or  discomfort  to  a  patient  who  is 
obliged  to  stand  much  of  the  time. 

Abduction  is  of  no  importance  unless  it  is  considerable.  It 
serves  in  most  instances  as  a  compensation  for  actual  shortening 
of  the  limb. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  407 

Adduction,  on  the  other  hand,  which  necessitates  an  upward 
tilting  of  the  pelvis  in  order  to  restore  the  parallelism  of  the 
limbs,  is  the.  most  disastrous  of  all  the  distortions,  since  it  causes 
a  practical  shortening  often  greater  than  that  due  to  the  destruc- 
tive effects  of  the  disease. 

The  motion  that  is  retained  after  recovery  from  hip  disease  is 
usually  considered  as  the  test  of  successful  treatment.  This  is 
by  no  means  the  fact,  for  in  many  instances  motion  is  preserved 
because  the  joint  is  destroyed  and  because  what  remains  of  the 
upper  extremity  of  the  femur  is  supported  by  the  tissues  on  the 
dorsum  of  the  ilium — a  form  of  pathological  dislocation.  Motion 
thus  explained  is  an  indication  of  inefficient  treatment  rather 
than  of  success,  for  in  such  cases  deformity  is  almost  always 
present,  and  the  support  is  insecure. 

Deformity  is  far  more  disabling  than  loss  of  motion,  and  the 
best  safeguard  against  final  deformity  is  to  prevent  it  during 
treatment,  and  to  retain  as  far  as  may  be  the  joint  surfaces  in 
proper  relation  to  one  another.  Whatever  motion  is  preserved 
will  then  be  of  service  to  the  patient,  and  eveUrif  anchylosis  fol- 
lows the  result  may  still  be  classed  as  good. 

Deformities  of  Other  Parts  Caused  by  Hip  Disease.- — Deformities 
of  other  parts  are  sometimes  observed  as  secondary  results  of  hip 
disease,  most  often  in  cases  that  have  not  received  proper  treat- 
ment. In  the  spine  an  exaggerated  lordosis  as  a  compensation 
for  flexion  is'  not  uncommon,  and  lateral  curvature  may  follow 
distortion  of  the  pelvis  caused  by  adduction.  In  the  limb  hnock- 
Jcnee  may  follow  persistent  adduction  of  the  thigh,  or  it  may  be 
an  effect  of  laxity  of  the  ligaments  without  such  distortion. 
Another  deformity  is  genu  recurvatum.  This  is  apparently 
caused  by  long-continued  disuse  of  the  limb,  and  by  the  use  of 
apparatus  in  which  the  knee  has  not  been  properly  supported. 
It  is  supposed  to  be  one  of  the  effects  of  traction,  but  it  is  also 
observed  in  cases  in  which  traction  has  never  been  employed. 
In  cases  in  which  the  muscular  atrophy  is  great,  laxity  of  the 
ligaments  of  the  knee-joint  is  common,  and  not  infrequently  sub- 
luxation of  the  tibia  also.  A  slight  degree  of  equinus  with  ac- 
companying exaggeration  of  the  arch  is  not  uncommon  among 
patients  who  have  been  treated  by  the  traction  apparatus,  in 
which  the  foot  is  pendent  and  in  which  the  toes  are  often  in- 
clined downward  to  guide  the  brace  in  walking.  Practically 
speaking,  all  these  secondary  deformities  may  be  avoided  by 
proper  supervision  of  the  patient  during  the  period  of  treatment. 


408  OBTEOFEBIC  SUBGEET. 

As  a  rule,  patients  who  have  recovered  from  hip  disease  finally 
discard  all  apparatus,  or  at  most  use  only  a  cane  as  a  support, 
and  many  prefer  to  walk  habitually  on  the  toe  rather  than  to 
equalize  the  length  of  the  limbs  by  a  high  shoe. 

By  far  the  larger  number  of  this  class,  having  accommodated 
themselves  to  whatever  weakness  and  distortion  may  be  present, 
are  able  to  undertake  the  ordinary  occupations  of  life.  Of  the 
cases  reported  by  Bradford  and  Soutter  98  per  cent,  of  the 
patients  recovered  with  useful  limbs.  Of  the  patients  treated  at 
the  IsTew  York  Orthopedic  Dispensary  and  Hospital  in  the  report 
already  referred  to,  in  whom  the  final  results  as  regards  motion 
■and  symmetry  were  certainly  not  above  the  average,  it  is  stated 
that  there  was  not  a  single  individual  who  was  incapacitated 
from  doing  a  full  day's  work  at  his  or  her  trade  or  occupation. 
ISTone  used  crutches  and  but  one  used  a  cane. 


CHAPTEK  VIII. 

NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP-JOINT. 

The  relative  frequency  and  importance  of  the  various  affec- 
tions of  the  liip- joint  that  cause  disability  are  indicated  by  the 
following  statistics  of  Koenig's-^  clinic  at  Gottingen : 

TulDerculous  clispase    568      =:       75  per  cent. 

Infectious  arthritis  following  typhoid  fever : 

Scarlatina  and  the  like 110 

Gonorrhoeal   arthritis    30 

Arthritis    deformans     22 

Injuries     11 

Contractions,  cause  unknown Q  Y=  -{-  25  per  cent. 

Coxa   vara    5 

Tumors    2 

Pyasmic   suppuration    3 

757 

Several  of  the  affections  enumerated  are  very  uncommon  in 
childhood,  while  injury  and  coxa  vara  are  relatively  more  im- 
portant. Coxa  vara  and  fracture  of  the  neck  of  the  femur  in 
early  life  are  considered  at  length  in  Chapter  XV. 

TRAUMATISMS   AT   THE   HIP-JOINT. 

It  is  probable  that  injury  at  the  hip-joint,  caused  by  falls  or 
strains,  may  induce  congestion  about  the  epiphyseal  cartilage  of 
the  head  of  the  femur.  In  this  class  of  cases  there  is  usually 
discomfort  at  night  after  overexertion,  "  growing  pain,"  and 
there  may  be  a  limp  and  restriction  of  motion.  These  symptoms 
may  disappear  in  a  few  days  or  they  may  recur  from  time  to 
time.  If  the  injury  is  more  severe  there  may  be  local  sensitive- 
ness and  even  swelling — synovitis.  This  congestion,  with  the 
lessened  local  resistance  induced  by  it,  may  be  a  predisposing 
cause  of  tuberculous  disease.  Injury  of  the  cartilage  and  of  the 
underlying  bone  may  cause  persistent  discomfort,  limitation  of 
motion  and  eventually  nutritive  changes  in  the  joint  (arthritis 
deformans  of  adolescence).  Undoubtedly  cases  of  this  type  are 
sometimes  mistaken  for  hip  disease  and  go  to  swell  the  number  of 
favorable  results  ascribed  to  one  or  another  system  of  treatment. 

Treatment. — All  cases  of  this  class   require  careful   super- 

^  Das  Hiiftgelenk,  Berlin,  1902. 
409 


410  OBTEOPEDIC  SUEGEEY. 

vision.  Strains  or  other  injuries  in  young  cHldren  are  best 
treated  by  a  supporting  bandage  and  by  rest  in  bed  until  the 
symptoms  disappear.  If  the  sensitive  condition  persists,  pro- 
tective treatment  by  a  brace,  preferably  the  ordinary  traction 
hip  splint,  or  by  a  short  plaster  bandage,  should  be  employed, 
the  diagnosis  being  resen-ed  until  it  is  made  clear  by  the 
progress  of  the  case.  Chronic  synovitis  of  the  hip-joint,  espe- 
cially in  the  adolescent  or  adnlt,  unless  it  is  a  direct  result  of 
injury,  is  usually  tuberculous  in  character. 

ARTHRITIS. 

Acute  Infectious  Arthritis — Acute  Epiphysitis  at  the  Hip- 
joint.- — Acute  epiphysitis,  caused  by  infection  mth  pyogenic 
germs,  is  not  uncommon  in  infancy  and  early  childhood.  Of 
iifty-two  cases  in  which  but  a  single  joint  was  involved  the  hip 
was  affected  in  twenty-six.^  In  some  instances  it  is  induced  or 
favored  by  injury,  in  others  it  is  secondary  to  an  infected 
wound,  and  it  may  follow  pneumonia  or  one  of  the  exanthemata. 

Symptoms. — The  symptoms  are  of  sudden  onset,  accompanied 
usually  by  high  fever  and  prostration.  The  hip  becomes  swollen, 
hot,  and  sensitive  both  to  motion  and  pressure. 

Treatment.- — The  treatment  is  early  and  free  incision  and 
efficient  drainage,  the  limb  being  afterward  supported  by  some 
form  of  splint.  In  neglected  cases  a  spontaneous  opening  forms 
and  suppuration  ordinarily  persists  for  several  months;  the 
epiphysis  is  usually  destroyed  in  whole  or  in  part,  and  in  conse- 
quence the  joint  becomes  somewhat  loose  and  flail-like  (Kg. 
287).  Many  of  these  cases  seen  in  later  years,  but  for  the  his- 
tory and  the  scars  about  the  joint,  might  be  mistaken  for  con- 
genital dislocation.  In  certain  instances  the  symptoms  are  less 
acute  and  the  diagnosis  from  tuberculous  disease  can  be  made 
positively  only  after  a  bacteriological  examination  of  the  fluid 
that  may  be  removed  from  the  joint  by  aspiration. 

In  the  class  of  cases  in  which  the  disease  is  confined  to  one 
joint  and  in  which  the  shaft  of  the  bone  is  not  involved,  the 
prognosis  is  good  if  the  pus  is  thoroughly  evacuated.  In  twelve 
cases  treated  at  the  Hospital  for  Ruptured  and  Crippled  there 
were  three  deaths.-  The  prognosis  as  to  function  under  these 
conditions  is  much  better  than  in  tuberculous  disease. 

After  recovery  the  joint  should  be  supported  for  a  time  in 

^  Townsend,  American  Journal  of  the  Medical  Sciences,  January,  1890. 
^  Townsend,  loc.  cit. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP-JOINT.    411 

extension  and  abduction  to  prevent  displacement.  If  the  head 
of  the  femnr  has  been  destroyed  there  is  usually  upward  and 
backward  dislocation.  This  induces  flexion  and  adduction  of 
the  limb  and  great  disability.  In  such  cases  one  should,  under 
anaesthesia,  force  the  femur  forward  to  the  neighborhood  of  the 
anterior  superior  spine  and  to  fix  it  there  for  a  long  period  by 
the  application  of  a  Lorenz  spica  bandage  applied  with  the  limb 
in  an  attitude  of  abduction  and  hyperextension.  The  operation 
is  in  detail  similar  to  the  Lorenz  method  for  replacing  the  con- 
genital dislocation.      (See  Congenital  Dislocation  of  the  Hip.) 

Subacute  Arthritis. — In  the  forms  of  arthritis  that  may  com- 
plicate infectious  diseases  several  joints  are  usually  involved, 
and  the  affection  is  often  subacute  in  character. 

tjndoubtedly  there  are  mild  cases  of  infection  at  the  hip-joint 
terminating  in  partial  or  complete  recovery.  In  such  cases, 
which  are  usually  classed  as  rheumatism,  there  is  usually  some 
infiltration  about  the  hip,  flexion  deformity,  limitation  of 
motion,  and  pain  or  discomfort  referred  to  the  affected  joint. 
A  satisfactory  treatment  is  the  application  of  ichthyol  ointment 
in  a  strength  of  about  25  per  cent.,  the  joint  being  fix;ed  by  a 
posterior  wire  splint  or  light  Thomas  hip  brace. 

Hoke  has  reported  cases  of  what  he  calls  toxic  arthritis  due 
to  intestinal  putrefaction.  Prompt  evacuation  of  the  bowels  and 
regulation  of  the  diet  are  the  first  indications  in  cases  of  this 

type. 

Gonorrhoeal  Arthritis. — Gonorrhoeal  arthritis  of  this  joint  is 
an  affection  not  uncommon  in  adult  life,  and  in  its  symptoms 
and  effects  it  may  resemble  tuberculous  disease  or  perhaps  more 
closely  osteoarthritis.  The  treatment  of  infectious  arthritis  in 
general  is  discussed  elsewhere.  Deformity  should  be  corrected 
by  rest  in  bed  with  traction,  and  protective  treatment  should  be 
employed  while  the  sensitiveness  persists.  The  short  spica 
plaster  bandage,  if  properly  applied,  is  a  satisfactory  support. 

SPONTANEOUS  DISLOCATION  OF  THE  HIP-JOINT. 

If  the  hip-joint  becomes  distended  with  fluid  the  capsule  may 
be  ruptured  and  sudden  displacement  may  occur. 

Degez^  has  collected  from  literature  seventy-nine  cases  of  this 
character.  The  displacement  occurred  in  the  course  of  the  fol- 
lowing diseases: 

'  Eevue  d  'Orthopedie,  January  1,  1899. 


41-2 


OETHOPEDIC  SUEGEBY. 


Typhoid  fever    32 

Kheumatism    24 

Scarlatina    13 

Variola     3 

Gonorrhoea!    arthritis     3 

La  grippe   2 

Erysipelas     1 

Eruptive  fever   1 


Fig.  287. 


Such  accidents^  mav  be  guarded  against  by  preventing  flexion 
and  adduction  or  extreme  outward  rotation  of  the  limb  and  by 
evacuation  of  the  fluid  that  distends  the  joint.  The  femur  should 
be  replaced  as  soon  as  possible  before  it  has  become  flxed  by  ad- 
hesions and  contractions.  Even  if 
treatment  has  been  delayed  for  months, 
by  means  of  preliminary  traction  and 
by  the  use  of  manual  force,  as  in  the 
reduction  of  congenital  dislocation,  one 
may  succeed  in  replacing  the  femur. 
In  cases  of  longer  standing  the  acetab- 
ulum is  usually  filled  with  new  mate- 
rial, which  must  be  removed  by  the 
open  method  before  replacement  is  pos- 
sible. As  an  alternative  operation  one 
may  force  the  head  of  the  femur  into 
the  anterior  position  and  fix  the  limb, 
for  several  months,  in  the  attitude  of 
extension  and  abduction.  If  the  out- 
ward rotation  is  excessive,  or  if  a  tend- 
ency toward  adduction  persists,  a  sec- 
ondary osteotomy  of  the  shaft  below  the 
trochanter  minor  may  be  performed. 
However  early  reduction  is  accom- 
plished, limitation  of  motion  is  to  be 
expected,  and  in  many  instances  abso- 
lute anchylosis.  On  this  account  the 
limb  should  be  supported  for  a  time  in 
proper  position  in  order  to  prevent  de- 
formity. 


The  later  effect  of  acute 
epiphysitis  of  the  right  hip 
at  three  months  of  age.  The 
scar  is  shown. 


EXTRA-ARTICULAR   DISEASE. 

Occasionally  tuberculous  disease,   or 
other  form  of  destructive  ostitis,   may 


1  Graff,  Deutsche  Zeits.  f.  CMr.,  February,  1902. 


NON-TUBEBCULOUS  AFFECTIONS  OF  THE  HIP-JOINT.    413 

begin  in  the  neighborhood  of  the  trochanter  major.  The  symp- 
toms are  local  pain,  sensitiveness,  and  swelling  of  the  soft  parts. 
Later  thickening  and  irregularity  of  the  underlying  bone  be- 
come evident. 

The  symptoms  are  limp  and  discomfort.  If  the  disease  in- 
volves the  capsule  or  is  sufficiently  acute  to  cause  sympathetic 
congestion  of  the  joint,  there  may  be  general  limitation  of 
motion;  but,  as  a  rule,  this  is  slight  or  absent.  In  many  in- 
stances the  focus  in  the  bone  may  be  demonstrated  by  an  X-ray 
negative.  If  the  disease  is  tuberculous  or  of  the  subacute  type, 
abscess  in  the  trochanteric  or  gluteal  region  may  be  the  first 
indication  of  disease. 

The  treatment  is  prompt  removal  of  the  focus  of  disease  before 
the  joint  or  the  shaft  of  the  femur  has  become  involved. 

Disease  of  the  pelvic  bones  in  the  neighborhood  of  the  joint 
may  simulate  hip  disease.  The  diagnosis  is  made  by  the  local 
swelling  and  sensitiveness,  and  by  the  freedom  of  motion  in  the 
directions  not  restrained  by  sensitive  tissues  that  are  involved 
in  the  disease. 

Gluteal  Bursitis. — An  enlargement  of  one  of  the  bursse  lying 
beneath  the  gluteal  muscles  may  cause  a  rounded,  fluctuating 
swelling  in  the  buttock.  It  may  be  sensitive  to  pressure  and  it 
usually  causes  a  limp  and  some  discomfort  on  motion,  dependent 
upon  the  degree  of  inflammation  that  may  be  present.  Occasion- 
ally the  bursitis  may  be  caused  by  injury,  but  in  most  instances 
it  is  the  result  of  tuberculous  infection.  The  bursa  may  com- 
municate with  a  diseased  hip-joint,  but  usually  it  is  a  distinct 
and  primary  affection. 

Iliopsoas  Bursitis, — The  iliopsoas  bursa  lies  in  front  of  the 
capsule  of  the  hip-joint,  extending  from  the  trochanter  minor  to 
and  sometimes  over  the  brim  of  the  pelvis.  JSTot  infrequently 
it  communicates  with  the  joint.  If  the  bursa  is  enlarged  it 
forms  a  swelling  in  Scarpa's  space  of  a  somewhat  quadrilateral 
form.  Sometimes  a  central  indentation  indicates  the  position 
of  the  iliopsoas  tendon.  This  causes  a  distinct  enlargement  of 
the  upper  and  inner  aspect  of  the  thigh.  It  is  usually  accom- 
panied by  slight  flexion,  abduction,  and  outward  rotation  of  the 
limb,  an  attitude  that  relieves  the  tension  on  the  sensitive  part. 
Zuelzer  has  collected  from  literature  forty-five  cases  of  gluteal 
and  fifteen  of  iliopsoas  bursitis.  This  illustrates  the  relative 
frequency  of  the  two  affections.^ 

^Deutsche  Zeits.  f.  Chir.,  Bd.  i.,  H.  1  uncle  2. 


414  ORTHOPEDIC  SUEGEBY. 

Simple  bursitis  may  be  distinguished  from  disease  of  tbe  joint 
by  the  absence  of  characteristic  muscular  spasm  and  general 
limitation  of  motion.  Acute  inflammation  of  a  bursa  may  simu- 
late local  abscess. 

Treatment.- — Chronic  disease  of  bursse  is  usually  tuberculous 
in  character.  Aspiration  and  injection  of  carbolic  acid  or  iodo- 
form emulsion  may  be  employed  as  primary  measures.  As  a 
rule,  however,  incision,  drainage,  or,  if  possible,  removal  of  the 
sac  is  indicated.  According  to  Lund,^  the  iliopsoas  bursa  may 
be  reached  easily  by  a  vertical  incision  between  the  femoral 
artery  and  the  crural  nerve. 

MALIGNANT  DISEASE   ABOUT   THE   HIP-JOINT. 

Carcinoma  of  the  upper  extremity  of  the  femur  is  almost 
always  secondary  to  a  primary  tumor  of  another  part  of  the 
body.  Sarcoma  is  far  less  frequent  in  this  situation  than  at  the 
knee.  The  character  of  the  disease  soon  becomes  evident  in  the 
general  enlargement  of  the  upper  extremity  of  the  thigh,  but  in 
the  early  stage  diagnosis  can  be  made  only  by  means  of  the 
X-ray  or  by  exploratory  incision. 

CYSTS  OF  THE  FEMUR. 

In  rare  instances  cysts,  caused  apparently  by  congenital  in- 
clusion of  a  displaced  portion  of  epiphyseal  cartilage,  may  cause 
enlargement,  weakening,  and  deformity  of  the  upper  extremity 
of  the  femur.  One  case,  in  a  boy  thirteen  years  of  age,  was 
treated  at  the  Hospital  for  Euptured  and  Crippled.  The  symp- 
toms were  discomfort,  limp,  and  outward  bowing  of  the  upper 
third  of  the  femur.  Cure  followed  its  removal.  Of  24  -p^ses 
reported  13  were  of  the  upper  extremity  of  the  femur,  1  of  the 
lower  end,  3  of  the  upper  extremity  of  the  tibia,  3  of  the  upper 
portion  of  the  humerus.  The  affection  is  usually  discovered  dur- 
ing the  growing  period,  injury  being  an  exciting  cause.  In  some 
instances  spontaneous  fracture  occurs.^ 

Cysts  may  be  caused  also  by  localized  osteomyelitis  of  a  mild 

character. 

ARTHRITIS  DEFORMANS. 

Osteoarthritis  of  the  Hip- joint. — Osteoarthritis  is  not  infre- 
quently confined  to  the  hip-joint.  In  this  form  it  is  practically 
an  affection  of  adult  life   or  old   age    (malum  coxse   senile )7 

^  Boston  Medical  and  Surgical  Journal,  September  25,  1902. 
=  Mikulicz,  Zeits.  f.  Chir.,  November  19,  1904. 


N0N-TUBEECUL0U8  AFFECTIONS  OF  THE  HIP-JOINT.    415 

although  cases  have  been  rej)ortecl  in  young  subjects.  It  is 
far  more  common  in  males  than  in  females.  It  is  characterized 
in  its  later  stages  by  disappearance  of  the  cartilage  covering  the 
head  of  the  femur  and  by  an  eburnation  and  progressive  destruc- 
tion, or  wearing  away,  of  the  underlying  bone  with  formation 
of  ecchondroses  about  the  junction  of  the  femur  with  the  ace- 
tabulum, which  become  ossified  into  irregular  masses  of  bone.  In 
the  early  stage  of  the  affection  the  fluid  within  the  joint  may  be 
increased  in  amount,  but  later  it  is  diminished  in  quantity  and 
changed  in  quality  as  the  synovial  membrane  becomes  trans- 
formed in  part  to  fibrous  tissue.  The  etiology  of  the  affection 
is  discussed  elsewhere.     (See  page  283.) 

Symptoms. — The  early  symptoms  are  usually  subacute  in  char- 
acter. They  are  neuralgic  pain  in  the  limb,  "  sciatic  rheuma- 
tism," stiffness  on  changing  from  rest  to  activity,  and  sensitive- 
ness to  direct  pressure  on  the  joint,  so  that  the  patient  often  lies 
habitually  on  the  other  side.  The  movements  of  the  joint  be- 
come somewhat  restricted,  and  the  patient  notices  that  he  can- 
not take  a  long  step  or  ride  with  comfort.  In  many  instances 
creaking  or  grating  in  the  joint  is  noticeable.  In  advanced 
stages  of  the  disease  there  is  marked  thickening  about  the  tro- 
chanter which  is  usually  displaced  upward,  owing  to  the  progres- 
sive changes  in  the  acetabulum  and  in  the  head  and  neck  of  the 
femur.  The  limb  is  shortened  and  it  is  often  distorted,  usually 
in  an  attitude  of  flexion  and  adduction,  and  marked  atrophy  is 
apparent,  appearances  that,  but  for  the  history,  might  be  mis- 
taken for  fracture.  So  also  in  the  earlier  period  of  the  disease 
the  limp,  the  pain,  and  restriction  of  motion  with  the  attendant 
atrophy  may  simulate  very  closely  tuberculous  disease  of  a  sub- 
acute type. 

The  progress  of  the  disease  may  be  slow  or  it  may  be  rapid. 
It  depends  in  great  degree  upon  the  strain  to  which  the  part  is 
subjected.     In  this  it  resembles  tuberculous  disease. 

Treatment. — In  the  class  of  cases  in  which  the  disease  is  con- 
fined to  a  single  joint  one  may  hope  to  check  the  progress  of  the 
destructive  process  by  lessening  the  strain  upon  the  joint  by 
regulation  of  the  patient's  habits  and  occupation,  and  to  im- 
prove the  nutrition  of.the  part  by  massage  and  local  stimulants. 
Passive  motion  in  the  directions  of  abduction  and  extension,  for 
the  purpose  of  preventing  secondary  contraction  of  the  muscles,, 
is  of  service  also. 

If  deformity  is  present  it  should  be  reduced  by  traction  and 


416  OBTHOPEDIC  SUEGEBY. 

rest  in  bed  or  by  carefully  regulated  force  under  anaesthesia. 
Afterward  the  symptoms  may  be  relieved  by  the  use  of  a  hip 
brace  (Fig.  272)  that  will  remove  the  weight  and  limit  the  range 
of  motion,  or  a  support  of  the  character  of  a  Lorenz  spica  of  plas- 
ter, leather,  or  other  material  may  be  used.  The  most  satisfactory 
treatment  of  confirmed  cases  is  the  induction  of  anchylosis  by 
Albee's  method.  The  joint  is  opened  by  an  anterior  incision 
along  the  inner  border  of  the  Sartorius  muscle.  The  upper  ex- 
tremity of  the  head  in  the  plane  of  the  neck  and  a  sufficient 
section  of  the  roof  of  the  acetabulum  are  cut  away  with  a  chisel 
so  that  the  two  surfaces  may  be  brought  into  accurate  apposition 
by  abducting  the  thigh,  preferably  about  10  or  15°.  To  attain 
this  attitude  tenotomy  of  the  adductors  may  be  necessary.  The 
wound  is  closed  and  the  limb  is  fixed  in  a  long  spica  bandage 
until  union  is  firm.  The  same  o^Deration  may  be  emplayed  for 
other  forms  of  chronic  disease  at  the  hip  joint  in  which  move- 
ment causes  pain. 

Lorenz  states  that  he  has  treated  cases  satisfactorily  by  in- 
ducing anterior  transposition  of  the  head  of  the  femur  and 
fixing  the  limb  for  a  time  in  an  attitude  of  extension  and  ab- 
duction. In  many  instances  neither  the  operative  nor  the  brace 
treatment  is  feasible,  but  the  use  of  a  firm  flannel  spica  bandage 
or  similar  support,  combined  with  the  application  of  cautery, 
from  time  to  time,  adds  to  the  comfort  of  the  patient. 


CHAPTEE  IX. 

TUBERCULOUS  DISEASE   OF   THE  KNEE-JOINT. 

Synonyms. — White  swelling,  tumor  albus. 

Tuberculous  disease  of  the  knee-joint  is  next  in  frequency  and 
importance  to  that  of  the  hip.  It  is,  however,  far  less  dangerous 
to  life,  and  the  prognosis,  as  regards  function,  is  much  better 
than  in  the  former  affection.  This  is  accounted  for  by  the 
simplicity  of  the  joint  and  by  its  situation  at  a  distance  from  the 
trunk,  at  the  junction  of  two  levers  of  nearly  equal  length  and 
size.    As  the  problem  of  protection  by  mechanical  means  is  com- 


:1 


Fig.  288. 


Section  of  knee-joint  at  the  age  of  eight  years, 
showing  the  epiphyses  of  the  femur  and  tibia  and 
their  relation  to  the  capsule.  (Krause.)  The 
centres  of  ossification  in  the  epiphyses  of  the 
femur  and  tibia  are  present  at  birth.  Ossification 
is  completed  in  each  at  about  the  twentieth  year. 

The  range  of  motion  is  from  slightly  more  than 
complete  extension  to  about  50  to  60  degrees.  In 
complete  extension  the  tibia  is  rotated  outward  on 
the  femur.  In  midflexion  the  laxity  of  the  liga- 
ments permits  a  range  of  inward  and  outward  ro- 
tation of  about  25  degrees. 


paratively  simple  it  is  more  often  applied,  and  in  proportion  to 
its  efficiency  the  injury  is  lessened  and  the  tendency  to  deformity 
is  checked. 

Pathology. — The  disease  may  begin  in  the  epiphysis  of  the 
femur  or  in  that  of  the  tibia,  occasionally  in  the  patella  or  in  the 
head  of  the  fibula,  or  primarily  in  the  synovial  membrane. 

In  547  cases, ^  about  two-thirds  of  which  were  in  adults, 
treated  at  Koenig's  clinic  at  Gottingen  by  operative  procedures 
which  permitted  inspection  of  the  joint,  281  (51.4  per  cent.) 
were  apparently  examples  of  primary  osteal  disease;  266  (48.6 

^  Die  Specielle  Tuberculose  der  Knochen  und  Gelenke,  Berlin,  1896. 
27  417 


418 


OETHOPEDIC  SUBGEB¥. 


per  cent.)  were  primarily  synovial.  The  focus  was  in  the  femur 
in  93  instances  (33.1  per  cent.),  in  the  tibia  in  107  (38.1  per 
cent.),  in  the  patella  in  33  (11.7  per  cent.),  and  in  more  than 
bone  in  48  (17.1  per  cent.). 

The  examination  of  a  joint  permitted  by  arthrectomy  or  ex- 
cision cannot  be  sufficiently  thorough  to  exclude  disease  of  the 
bone  and  to  establish  the  diagnosis  of  primary  disease  of  the 
synovial  membrane,  but  in  92  instances  the  opportunity  was 
offered  by  amputation  at  the  thigh,  80  of  the  patients  being 
adults.      This  examination,  presumably  thorough,   showed  the 

Fig.  289. 


Acute  tuberculous  arthritis  of  the  knee. 


primary  disease  to  be  of  the  bone  in  50  cases,  while  in  35  the 
synovial  membrane  was  apparently  the  seat  of  the  primary  affec- 
tion. In  17  of  the  50  cases  in  which  the  disease  was  osteal,  the 
focus  was  in  the  femur;  in  7  it  was  in  the  internal  condyle,  in 


TUBEBCULOUS  DISEASE  OF  THE  KNEE-JOINT. 


419 


Fig.  290. 


6  in  the  external  condyle,  and  it  was  in  other  situations  in  4 
cases.  In  17  the  primary  disease  was  of  the  tibia ;  in  5  of  the 
internal  tuberosity ;  in  5  of  the  external  tuberosity ;  in  other 
situations  7.  In  5  instances  the  primary  disease  was  of  the 
patella,  and  more  than  one  bone  was  involved  in  11  cases. 
Nichols-^  states  that  he  has  examined  120  tuberculous  joints  of 
adults  and  children,  after  excision 
or  amputation,  or  at  autopsy,  and 
in  every  instance  primary  foci  in 
the  bone  were  discovered.  He  be- 
lieves primary  disease  of  the  syno- 
vial membrane  to  be  very  uncom- 
mon, and  asserts  that  examina- 
tions are  of  no  particular  value 
as  establishing  the  absence  of  pri- 
mary osteal  disease  unless  the 
bones  are  sawed  into  thin  sections. 
From  the  clinical  standpoint, 
however,  one  recognizes  two  dis- 
tinct types  of  tuberculous  disease : 
one  beginning  as  a  chronic  syno- 
vitis of  which  the  early  symptoms 
are  subacute,  a  type  more  often 
seen  in  adults  (Fig-  290)  ;  and  the 
more  common  class,  in  which  the 
symptoms  of  pain,  muscular 
spasm,  and  deformity  seem  to  in- 
dicate clearly  primary  disease  of 
the  bone. 

The  proximity  of  the  active  dis- 
ease in  the  neighborhood  of  the 
joint  sets  up  a  sympathetic  hypersemia  within  it,  and  an  accom- 
panying synovitis.  If  the  disease  is  progressive  the  synovial 
membrane  becomes  thickened  and  adhesions  form  between  its 
folds  that  gradually  lessen  the  capacity  of  the  joint  and  diminish 
its  mobility.  When  perforation  takes  place  the  granulation 
tissue  spreads  over  the  surface  of  the  cartilages,  destroying  them 
in  its  progress  and  eroding  the  underlying  bone;  or  if  the  joint 
is  filled  with  tuberculous  fluid  the  cartilage  may  be  macerated 
and  separated  in  necrotic  shreds.  The  direct  destructive  effects 
of  the  disease  are  increased  by  pressure  and  friction  if  the  joint 

^  Transactions  American   Orthopedic  Association,  vol.  xi. 


Tuberculous  disease  of  the  knee  in. 
an   adult.     The  synovial   type. 


420 


OBTHOPEDIC  SUEGEBY. 


is  not  protected  hj  mechanical  means.  The  hjpertrophied  syn- 
ovial membrane  and  the  thickened  and  diseased  capsule  explain 
the  peculiar  elastic  resistance  on  palpation  called  pseudofluctua- 
tion.  In  more  advanced  cases  there  is  also  a  reactive  inflamma- 
tion in  the  overlying  tissues,  accompanied  by  a  formation  of 
fibrous  tissue  that  involves  the  tendons  and  muscles.  These 
changes  within  and  without  the  joint  cause  the  firm,  resistant 
tumor  characteristic  of  "  white  swelling." 

Etiology. — The  etiology  of  tuberculous  disease  has  been  dis- 
cussed in  Chapters  V.  and  YII. 

Occurrence, — Tuberculosis  of  the  knee-joint  is  essentially  a 
disease  of  early  life,  although  it  is  less  strictly  confined  to  child- 
hood than  is  disease  of  the  sj)ine  or  hip.  Sex  exercises  but  little 
influence,  and  the  two  sides  are  affected  in  nearly  equal  numbers. 
These  points  are  illustrated  by  the  following  table  of  1000  con- 
secutive cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled.-^ 


Age  at  Incipiency  of  Kxee-joint  Disease. 


year  or 


years 
years  o 
years  o 
years  o 

6  years  o 

7  years  o 

8  years  o 

9  years  o 

10  years  o' 

11  years 

12  years  o 

13  years  o 

14  years  o 

15  years  o 

16  years  o 

17  years  o 

18  years  o 

19  years  o 

20  years  o 

21  years  o 

22  years  o 


less. 
Id.  .. 
Id... 
Id.  .  . 
ild.  .. 
Id... 
Id.  . . 
Id.  .. 
Id.  .. 
Id... 
Id... 
Id.  .. 
Id... 
Id.  . . 
Id... 
Id . . . 
Id... 
Id... 
ild. . . 
Id... 
Id.  .. 
Id.  .. 


25 
45 
91 
164 
84 
75 
66 
74 
65 
60 
46 
20 
19 
17 
12 
10 
20 


8 
12 
13 


23  years  o 

24  years  o 

25  years  o 

26  years  o 

27  years  o 

28  years  o 

29  years  o 

30  years  o 

31  years  o 

32  years  o 

33  years  o 

34  years  o 

35  years  o 

36  years  o 

37  years  o 

38  years  o' 

39  years  o 

40  years  o 

41  years  o' 
50  years 


12 
8 
3 
2 
4 
5 
7 
1 
1 
2 

1 
1 
4 
0 
2 
1 
1 
1 
1 
1 


1000 


Males 512 

Females 488 


Eight. 
Left. . 


485 
515 


Symptoms. — The  general  characteristics  of  tuberculosis  have 
been  described  in  the  chapters  on  Pott's  disease  and  hip  disease. 
In  the  description  of  these  affections,  however,  but  little  stress 

^  These  statistics,  together  with  those  of  tuberculous  disease  of  the  joints, 
other  than  of  the  hip,  were  collected  for  me  by  Drs.  F.  C.  Bradner,  S.  E. 
Sprague,  E.  L.  Barnett,  and  S.  W.  Stone,  formerly  house  officers  at  the 
hospital. 


TUBEBCULOUS  DISEASE  OF  TEE  KNEE-JOINT. 


421 


was  laid  on  local  sensitiveness  and  local  swelling,  because  the 
diseased  parts  lie  at  a  distance  from  the  surface  and  are  con- 
cealed by  the  muscles  and  other  tissues.  At  the  knee,  on  the 
other  hand,  the  joint  is  superficial,  and  even  slight  effusion 
changes,  to  a  perceptible  degree,  its  contour.  If  the  disease  is 
progressive,  sensitiveness  to  pressure,  elevation  of  the  local  tem- 
perature, and  infiltration  or  thickening  of  the  tissues  are  usually 
present. 

Even  when  the  patients  are  seen  comparatively  early  in  the 
course  of  the  disease  the  history  of  the  affection  almost  always 
indicates  that  it  is  chronic  and  progressive  in  character.  The 
importance  of  establishing  this  fact  has  been  mentioned  in  the 
consideration  of  hip  disease,  and  it  may  be  stated  again  that  a 
chronic  painful  disease  of  a  single  joint,  accompanied  by  a  ten- 
dency to  deformity,  is,  in  childhood,  almost  always  tuberculous 
in  character. 

The  symptoms  of  tuberculous  disease  may  be  classified  as 
limpj,  'pain,  local  heat,  sensitiveness  and  swelling ,  muscular  spasm 
and  limitation  of  m,otion,  distortion  and  atrophy. 

Fig.  291. 


Flexion   deformity  at  the  knee-joint,   witti   slight  subluxation   of  the  tibia. 


On  physical  examination  one  w^ll  note  the  character  of  the 
limp  and  the  slight  flexion  of  the  limb  that  usually  accompanies 
it.  The  joint  is,  as  a  rule,  somewhat  enlarged,  the  normal  de- 
pressions about  the  patella  and  the  prominences  of  the  component 
bones  being  less  accentuated  than  on  the  opposite  side.  There  is 
usually  slight  local  elevation  of  temperature  and  sensitiveness  to 
pressure,  varying  in  degree  with  the  character  of  the  disease. 
In  certain  cases  effusion  is  present,  sufficient  to  be  classed  as 
synovitis,  but  in  most  instances  the  swelling  is  due,  in  great  part, 


422 


OBTEOPEDIC  SUBGEBT. 


to  the  thickening  of  the  synovial  membrane  and  capsule,  which 
gives  the  sensation  of  elastic  resistance  rather  than  of  actual 
fluctuation. 

Limitation  of  Motion. — The  most  important  diagnostic  sign  is 
limitation  of  the  range  of  motion  caused  by  muscular  spasm. 
The  normal  range  is  from  complete  extension  (180  degrees) 
to  a  degree  of  flexion,  limited  by  contact  of  the  calf  and  the 
thigh.  Even  in  the  early  stage  of  disease  slight  limitation  of 
complete  extension  is  present,  due  to  reflex  muscular  spasm,  and 
usually  a  corresponding  limitation  of  the  complete  flexion.  On 
sudden  movements  the  characteristic  reflex  contraction  of  the 
muscles  is  apparent.  In  most  cases  this  limitation  of  motion 
and  consequent  flexion  deformity  is  well-marked  on  the  first 
examination.  Atrophy  of  the  muscles  of  the  thigh  and  calf, 
dependent  upon  the  duration  of  the  disease  and  upon  the  inter- 
ference with  function,  is  present,  and  this  atrophy  is  more 
noticeable  because  of  the  enlargement  of  the  knee. 

Fig.  292. 


After  forcible  correction,  showing  the  increase  of  the  posterior  displacement 
Drawing  from  the  x-vaj  photographs  of  an  actual  case  in  which  the  limb  had 
been  corrected  by  direct  force  in  the  ordinary  manner.  See  reverse  leverage. 
Fig.  295. 

In  certain  cases,  more  often  seen  in  infancy  and  early  child- 
hood, the  symptoms  are  more  acute  and  the  progress  of  the 
disease  is  so  rapid  that  it  may  simulate  an  infectious  epiphysitis 
(Fig.  289). 

In  another  type,  apparently  a  primary  disease  of  the  synovial 
membrane,  more  common  in  •  adults,  the  early  symptoms  are 
very  similar  to  those  of  simple  chronic  synovitis.  The  joint  is 
swollen  by  a  distention  of  the  capsule,  pain  is  not  troublesome 
except  on  jars  or  sudden  twists  of  the  limb,  and  muscular  spasm 
and  limitation  of  motion  are  evident  only  after  a  careful  ex- 
amination.    In  this  class,  months  or  years  may  pass  before  the 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.  423 

symptoms  become  as  disabling  as  in  the  osteal  type  of  the  disease. 

Primary  and  Secondary  Distortions.. — At  the  hip-joint,  in  which 
the  range  of  motion  is  extensive,  the  deformities  resulting  from 
disease  are  somewhat  complex,  causing,  for  example,  apparent 
shortening  or  lengthening,  according  as  the  limb  is  adducted 
or  abducted.  But  the  movements  that  the  knee-joint  permits 
are  much  simpler,  and  the  primary  distortion  is  simply  flexion. 
Complete  extension  of  the  limb,  the  limit  of  normal  motion  in 
that  direction,  brings  the  joint  surfaces  into  close  apposition; 
the  ligaments  are  then  tense  and  no  lateral  motion  is  permitted. 
This  is  the  attitude  in  which  the  greatest  efficiency  of  the  limb 
for  weight  bearing  is  assured.  When  the  ability  of  the  knee 
for  carrying  out  its  normal  weight-bearing  function  is  impaired 
by  disease  which  makes  the  parts  sensitive  to  pressure  and  strain, 
the  range  of  extension  is  lessened  and  the  limb  is  persistently 
flexed  to  a  greater  or  less  degree,  corresponding  to  the  sensitive- 
ness of  the  joint.  The  agents  that  adapt  the  limb  to  the  habitual 
attitudes  are  the  muscles  under  the  control  of  the  nervous  system. 
In  this  sense  the  primary  distortions  are  due  to  muscular  action, 
but  it  is  certainly  not  true  that  these  muscles  antagonize  one 
another,  and  that  the  stronger  overcoming  the  weaker  cause 
the  deformity,  since  the  extensors  at  this  joint  are  stronger  than 
the  flexors,  and  since  flexion  is  the  primary  deformity  at  every 
joint  which  is  diseased  without  regard  to  the^  relative  strenglih 
of  the  opposing  muscular  groups. 

In  disease  at  the  knee-joint,  as  at  other  joints,  the  extremes  of 
motion  in  every  direction  that  the  joint  permits  are  limited  by 
muscular  spasm,  but  limitation  of  extension,  which  is  so  essential 
to  normal  use,  is  at  once  evident,  while  limitation  of  flexion,  the 
extreme  of  which  is  unessential,  is  only  apparent  on  examina- 
tion, and  it  may  be  absent  even.  Flexion  is,  then,  the  primary 
distortion  at  the  knee,  and  other  deformities  may  be  classed  as 
secondary. 

Secondary  Deformities. — Of  these  the  most  common  is  outward 
rotation  of  the  tibia  upon  the  femur.  When  the  limb  is  fully 
extended  the  tibia  is  fixed,  but  when  it  is  flexed  lateral  motion 
is  possible,  and  in  the  attitude  of  flexion  the  traction  of  the 
biceps  upon  the  head  of  the  fibula  tends  to  rotate  it  upon  the 
femur.  This  deformity  is  also  favored  by  the  use  of  the  limb 
in  the  attitude  of  outward  rotation,  which  is  always  assumed 
when  the  weakness  or  stiffness  of  the  knee-joint  is  present,  and 
by  the  secondary  knock-knee  that-  often  accompanies  the  disease. 


424 


OETHOPEDIC  SUBGEBY. 


Subluxation  or  backward  displacement  of  the  tibia  upon  the 
femur  is  anotheriecondary  deformity.  WFen  tEe  leg  is  flexed 
upon  the  thigh  the  articulating  surface  of  the  tibia  glides  back- 
ward upon  the  condyles  of  the  femur.  Here  it  becomes  fixed  by 
muscular  contraction,  and  later  by  the  secondary  changes  within 
the  joint.    If  muscular  spasm  is  extreme,  this  alone  may  cause 

Fig.  293. 


Untreated  disease  of  the  knee-joint  involving  tlie  shaft  of  the  femur,  illus- 
trating lengthening  and  the  hypertrophy  of  the  femur,  the  subluxation  and  out- 
ward rotation  of  the  tibia,  the  atrophy  and  the  characteristic  deformity. 


the  subluxation ;  but  there  are  other  factors :  one  is  the  destruc- 
tive action  of  the  disease,  which  is  usually  most  marked  at  the 


TUBEECUL0U8  DISEASE  OF  THE  KNEE-JOINT.  425 

point  at  which  the  bones  are  in  contact,  and  the  other  is  the 
leverage  exerted  upon  the  joint.  This  is  exemplified  by  the 
increase  of  the  displacement  that  is  often  observed  when  an 
attempt  is  made  to  straighten  the  limb  by  force,  against  the 
resistance  offered  by  the  contracted  tissues  on  the  flexor  aspect. 
The  same  leverage,  in  slighter  degree,  is  exerted  when  the  weight 
of  the  distorted  limb  is  supported  on  the  heel  in  the  recumbent 
posture,  or  when  the  limb  is  extended  in  the  act  of  walking,  or 
if  the  upper  extremity  of  the  tibia  is  not  supported  during  the 
period  of  treatment  by  apparatus  (Fig.  292). 

Knock-knee  (genu  valgum)  is  another  secondary  deformity. 
This  is  explained  in  certain  instances  by  the  hypertrophy  of  the 
internal  condyle  caused  by  disease,  but  it  is  induced  more 
directly  by  the  use  of  the  flexed  and  somewhat  disabled  limb  in 
the  passive  attitude  of  outward  rotation.  Genu  varum  is  un- 
common, and  it  is  usually  the  result  of  the  destruction  of  a  part 
of  the  internal  condyle  of  the  femur  or  of  the  tibia,  or  of  irregu- 
lar epiphyseal  growth. 

The  character  and  the  relative  frequency  of  the  deformities 
are  indicated  by  the  statistics  of  Koenig's^  clinic,  of  150  cases 
of  knee-joint  disease  treated  by  arthrectomy,  128  of  these  being 
in  children.  In  94  cases  flexion  was  present;  in  50,  from  a 
slight  degree  to  135  degrees;  in  16,  from  135  degrees  to  90;  in 
28^  to  a  right  angle  or  less.  Together  with  the  flexion  were 
combined  other  deformities  as  follows :  Genu  valgum  in  60 
cases;  moderate  in  42;  extreme  in  18.  Genu  varum  in  1  case. 
Subluxation  of  the  tibia  in  20  cases.  Outward  rotation  of  the 
tibia  in  10  cases. 

As  has  been  stated,  the  primary  deformity  of  knee  disease  is 
simple  flexion.  If  the  disease  is  of  an  acute  type  this  flexion 
increases  rapidly.  If  it  is  subacute  in  character,  or  if  the  dis- 
ease is  primarily  of  the  synovial  membrane,  the  progress  of  the 
deformity  is  slow.  In  ordinary  cases  secondary  distortions  ap- 
pear at  a  later  time  and  especially  when  the  disease  has  reached 
the  destructive  stage;  and  they  are  most  marked  in  patients 
who  have  persistently  used  the  deformed  limb  without  pro- 
tection. 

Actual  Shortening  and  Actual  Lengthening. — Retardation  of 
growth  is,  of  course,  not  an  early  symptom  of  disease ;  in  fact, 
actual  lengtbening^^ofjthejimb,  due  to  the  irritative  effect  of  the 
disease  upon  the  epiphyseal  cartilage  of  the  femur  or  of  the 

^  Log.  cit. 


426  OBTHOPEDIC  SUEGEEY. 

tibia,  is  common.  This  lengthening,  sometimes  to  the  extent  of 
an  inch  or  even  more,  may  persist  throughout  the  entire  course 
of  treatment,  but  after  the  cure  of  the  disease  a  corresponding 
retardation  of  growth  that  will  more  than  equalize  the  length  of 
the  limbs  may  be  expected.  If  the  disease  is  of  the  destructive 
type  the  ultimate  shortening  may  be  considerable ;  two  or  more 
inches  is  not  unusual. 

Leusden,^  in  33  cases  under  treatment  in  the  clinic  at  Got- 
tingen,  1896-1898,  found  slight  shortening  in  2,  equality  of 
length  in  18,  lengthening  of  the  femur  on  the  diseased  side  in  13. 

In  one  hundred  and  sixteen  cases  of  tuberculous  disease  of 
the  knee  the  limbs  were  measured  by  Berry  and  Gibney^  with 
reference  to  this  poiiit.  In  72  of  these  there  was  actual  length- 
ening of  the  femur,  from  which  it  may  be  inferred  that  in  at 
least  26  per  cent,  of  the  cases  examined  the  primary  disease  was 
of  the  femur. 

In  17 ; %  inch. 

In  34 %  ineh. 

In  15 %  inch. 

In  6 , 1   inch. 

72  =  62  per  cent. 

H.  L.  Taylor,^  from  an  examination  of  40  cases  of  tuberculous 
disease  of  the  knee,  concludes  that  the  limb  is  almost  always 
longer  in  the  first  two  years  of  the  disease,  usually  longer  dur- 
ing the  second  two  years,  but  usually  shorter  when  the  period  of 
growth  is  completed.  The  lengthening  is  in  most  instances  of 
the  femur. 

Diagnosis. — Tuberculous  disease  is  a  local  destructive  process 
that  is,  as  a  rule,  confined  to  a  single  joint.  This  is  an  im- 
portant point  in  the  differential  diagnosis  from  general  or  con- 
stitutional affections  like  rheumatism,  arthritis  deformans,  and 
the  like,  in  which  several  joints  are  involved.  The  following 
affections  may  be  considered  in  differential  diag-nosis. 

Injury  of  the  Knee, — Strains  of  the  knee  in  childhood  are  often 
followed  by  limp  and  by  persistent  flexion  and  pain.  In 
such  cases  the  onset  is  sudden  and  the  symptoms  usually  disap- 
pear quickly  under  treatment.  Synovitis  of  traumatic  origin  is 
usually  indicative  of  a  more  severe  injury.  If  it  persists  the 
diagnosis  may  be  doubtful  because  tuberculous  infection  may 
have  followed  the  original  injury.     This  emphasizes  the  im- 

^  Deutsche  Zeits.  f.  Chir.,  BcT.  li.,  H.  3  unci  4. 

^  American  Journal  of  the  Medical  Sciences,  October,  1893. 

*  Transactions  American  Orthopedic  Association,  1901,  vol.  xiv. 


TUBEECULOUS  DISEASE  OF  THE  KNEE-JOINT.  427 

portance  of  the  careful  treatment  and  continued  observation  of 
injuries  of  this  class,  especially  in  weakly  children. 

Synovitis. — Chronic  synovitis  of  doubtful  origin,  which  shows 
no  tendency  toward  recovery,  is  in  childhood  almost  always 
tuberculous  in  character. 

Haemarthrosis. — Effusion  of  blood  into  the  knee-joint  may 
cause  inflammatory  symptoms  during  the  stage  of  absorption 
and  organization  of  the  clot  that  resemble  those  of  disease.  The 
sudden  onset  and  the  personal  history  of  the  patient,  who  may 
be  known  as  a  bleeder,  will  explain  the  symptoms. 

Infectious  Arthritis,^ — This  is  of  sudden  onset,  attended  by  the 
constitutional  and  local  symptoms  of  acute  infection. 

Rheumatism. — This,  in  early  childhood,  may  be  confined  to  a 
single  joint,  but  it  is  of  sudden  onset,  it  is  usually  accompanied 
by  constitutional  disturbance,  and  after  a  time  other  joints  be- 
come involved. 

Arthritis  Deformans, — Diseases  of  this  character,  of  the  mon- 
articular form,  are  more  common  in  adult  life.  The  symptoms 
are  rather  of  the  rheumatic  than  of  the  tuberculous  type. 

Charcot's  Disease. — Charcot's  disease  of  the  knee-joint  is  char- 
acterized by  sudden  effusion,  by  rapid  destruction  of  the  joint, 
and  consequently  by  weakness  and  deformity;  but  pain  is 
usually  very  slight  and  muscular  spasm  is  absent.  The  diag- 
nosis of  disease  of  the  spinal  cord  will  indicate  the  nature  of  the 
local  process  of  the  joint. 

Sarcoma. — Sarcoma,  beginning  at  or  near  the  extremity  of  the 
femur  or  of  the  tibia,  may  simulate  tuberculous  disease  very 
closely.  If  the  tumor  is  of  the  periosteal  type,  it  usually  forms 
a  more  localized  and  irregular  swelling  than  could  be  accounted 
for  by  tuberculous  disease.  Central  sarcoma  may  simulate 
tuberculous  disease  also,  but  the  progress  of  the  tumor  is  more 
rapid.  The  clinical  distinction  between  the  two  is  that  tuber- 
culous disease  is  very  amenable  to  treatment  as  far  as  its  symp- 
toms are  concerned,  while  the  progress  of  sarcoma  is  but  little 
influenced  by  treatment.  It  may  be  stated,  however,  that  the 
X-ray  is  the  only  means  of  early  diagnosis,  the  destruction  of 
the  substance  of  the  bone  about  the  tumor  being  much  greater 
than  that  caused  by  the  tuberculous  process. 

Hysterical  Joint, — Some  of  the  symptoms  of  disease  may  be 
simulated  by  hysterical  subjects,  but  there  is  always  an  absence 
of  the  positive  physical  signs  that  invariably  accomj)any  a  de- 


428  OBTEOPEDIC  SUBGEBY. 

structive  disease.     These  and  other  affections  are  described  at 
length  in  the  following  chapters. 

Treatment.- — The  treatment  of  tuberculous  disease  of  the  knee 
in  childhood  should  be  conservative,  operative  intervention 
being  simply  incidental  to  protective  treatment.  In  adult  life, 
on  the  other  hand,  the  radical  removal  of  the  disease  may  be 
indicated  as  primary  measure.  The  reasons  for  this  distinc- 
tion are  obvious.  In  childhood  the  duration  of  treatment  is  of 
no  particular  importance  as  compared  with  the  final  functional 
result,  but  in  adult  life  the  shortening  of  the  period  of  disability 
and  the  definite  assurance  of  cure  may  be  of  far  greater  moment 
than  the  preservation  of  motion. 

In  childhood,  under  favorable  conditions,  ultimate  recovery, 
with  fair  functional  use  of  the  joint,  may  be  anticipated;  while 
a  radical  operation,  although  it  may  cure  the  patient  in  a 
shorter  time,  takes  away  the  possibility  of  a  cure  with  motion. 
In  adult  life  a  rigid  limb  is  a  strong  and  useful  support,  but 
in  childhood  the  removal  of  portions  of  the  epiphyses  and  of  the 
epiphyseal  cartilages  entails  a  progressive  inequality  in  the 
limbs,  due  to  loss  of  growth ;  furthermore  unless  the  limb  is  pro- 
tected by  mechanical  means  deformity  is  the  rule,  even  though  the 
disease  has  been  thoroughly  removed.  Thus  the  treatment  of 
routine  is,  in  childhood,  at  least,  protection ;  protection  from  the 
traumatism  of  motion,  from  the  shock  of  impact  with  the 
ground,  and  from  the  pressure  of  muscular  spasm  and  con- 
traction. 

•  Fixation  of  the  joint,  which  is  so  difficult  to  assure  at  the  hip, 
is  easily  attained  at  the  knee,  and,  as  has  been  stated,  the  results 
are  correspondingly  better.  At  the  hip-joint  one  of  the  most 
common  causes  of  shortening  and  deformity  is  upward  displace- 
ment of  the  femur  upon  the  pelvis,  but  at  the  knee,  if  the  limb 
is  supported  in  the  attitude  of  extension,  the  apposition  of  the 
broad  surfaces  of  the  femur  and  the  tibia  prevents  displacement, 
while  muscular  spasm,  a  symptom  whose  intensity  is  in  propor- 
tion to  the  degree  of  harmful  motion  that  is  permitted,  is  easily 
controlled. 

Reduction  of  Deformity.. — The  first  step  in  treatment  is  the 
reduction  of  deformity  that  may  be  present,  and  as  the  chief 
function  of  the  leg  is  to  support  weight,  the  proper  attitude  in 
which  to  fix  the  limb  is  complete  extension.  Whatever  motion 
the  patient  retains  will  then  be  about  the  point  of  greatest  use- 
fulness.    In  the  cases  in  which  an  opportunity  for  reasonably 


TUBEBCULOUS  DISEASE  OF  THE  KNEE-JOINT. 


429 


early  treatment  is  offered  the  only  deformity  is  flexion  induced 
by  muscular  contraction.  In  this  class  of  cases  the  spasm,  and 
consequently  the  deformity,  may  be  readily  overcome  by  placing 
the  joint  at  rest. 

The  Plaster  Splint.- — The  most  efficient  splint  for  this  pre- 
liminary treatment  is  a  close-fitting  plaster  support,  applied 
from  the  groin  to  the  ankle,  or  better,  to  include  the  j)elvis  and 
the  foot,  to  prevent  oedema  of  the  unsupported  part,  which  is 
common  after  the  first  dressing  and  until  the  circulation  of 
the  limb  has  become  adapted  to  the  new  conditions.  In  the 
application  of  the  bandage  the  bony  prominences  of  the  knee 
and  ankle  are  protected  by  cotton.  A  cotton  flannel  bandage 
is  then  applied  smoothly,  and  directly  upon  this  the  light  plas- 
ter bandage.  At  the  second  application,  at  the  end  of  a  week, 
the  subsidence  of  the  spasm  will  permit  the  straightening  of 
the  limb.  In  cases  of  longer  standing  several  successive  ap- 
plications of  the  bandage  may  be  required,  together  with 
manual  extension  during  the  application ;  or  an  anaesthetic  may 
be  administered.  Under  anaesthesia  the  muscular  spasm  relaxes 
and  deformity,  even  of  some  standing,  may  be  reduced  by  trac- 
tion and  by  slight  leverage,  the  head  of  the  tibia  being  sup- 
ported and  drawn  forward  by  the  hands  as  the  deformity  is 
gently  reduced. 

Traction. — Deformity  may  be  reduced  also  by  traction  with 
the  weight  and  pulley,  the  leg  being  supported  so  that  no  direct 
leverage  is  exerted  at  the  seat  of  the  disease  (Fig.  294). 


FiCx.  294. 


Traction  and  countertraction  in  disease  of  tlie  linee-joint.      (Marsh.) 

Forcible  Correction  by  Reverse  Leverage — In  the  more  resistant 
cases,  especially  if  accompanied  by  subluxation,  the  following 
method  should  be  employed. 

The  patient  is  anaesthetized  and  is  placed  face  downward  on 
a  table,  the  feet  projecting  over  its  end.     The  body  of  the 


430 


OBTEOPEDIC  SUEGEBY. 


patient  is  then  elevated  by  means  of  pillows  to  conform  to  the 
deformity— that  is,  the  thigh  is  raised  sufficiently  to  permit  the 
tibia  to  lie  evenly  upon  the  anterior  border  on  the  table.  The 
operator  then  holds  the  head  of  the  tibia  firmly  against  the 
table  while  the  assistant  exerts  intermittent  and  gradually  in- 
creasing downward  pressure  on  the  thigh,  but  never  to  the 
extent  to  lift  the  tibia  from  the  table ;  thus,  further  subluxation 
is  impossible.  As  the  contraction  gives  way  the  pillows  are 
removed.  Usually  the  deformity  may  be  reduced  at  one  sitting, 
but  if  it  is  very  resistant  complete  correction  is  not  attempted. 
At  the  conclusion  of  the  operation  adhesive  plaster  straps  for 
traction  and  a  close-fitting  plaster  bandage  are  applied  (Fig. 
295). 

Rest  in  bed  with  traction  is  enforced  for  a  time,  and  the  ordi- 
nary brace  is  then  applied.     This  is,  in  the  author's  experience, 


Fig.  295. 


The  author's  method  of  correcting  flexion  deformity  at  the  knee  by  reverse 
leverage.  The  folded  sheet  indicates  the  degree  of  subluxation  present.  In 
resistant  cases  of  this  type  an  assistant  applies  the  pressure  on  the  thigh. 

the  most  effective  and  satisfactory  method  for  reducing  de- 
formity. If  the  contraction  is  of  long  standing  preliminary 
open  division  of  the  flexor  tendons  is  advisable.  The  deformity 
is  then  in  part  corrected,  complete  rectification  being  deferred 
until  repair  is  complete. 

The  Billroth  Splint. — The  Billroth  splint,  as  modified  by  Still- 
man,  IS  an  effective  appliance  for  overcoming  resistant  de- 
formity. A  thick  pad  of  felt  is  placed  over  the  upper  surface 
of  the  condyles  of  the  femur  and  a  thinner  pad  in  the  popliteal 
region  over  the  upper  border  of  the  tibia.  Other  points  that 
may  be  subjected  to  pressure  are  similarly  protected,  especially 
the  dorsum  of  the  foot  and  the  perineum.    A  plaster  bandage  is 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.  431 

then  applied  from  the  groin  to  the  toes,  made  especially  thick 
and  strong  in  the  popliteal  region.  On  either  side  of  the  knee 
two  curved,  slotted  steel  bars  attached  to  expanded  tin  splints 
and  joined  to  one  another  by  an  adjustable  bolt  are  incorporated 
in  it  (Fig.  296).  When  the  bandage  hardens  it  is  completely- 
divided  into  two  parts  by  a  circular  cut  about  the  knee,  and  the 

Fig.  296. 


Tuberculous  disease  of  the  knee   in   an  adult,   with   the   form  of  Billroth   splint 
used  at  the  Hospital   for  Ruptured  and   Crippled. 

bolts  in  the  slots  are  so  adjusted  as  to  form  a  hinged  splint, 
the  centre  of  motion  being  somewhat  above  and  in  front  of  the 
knee-joint.  When  the  limb  is  slightly  extended  the  position  of 
the  hinges  has  a  tendency  to  lift  the  tibia  and  to  separate  it  from 
the  femur.  This  straightening  opens  the  cut  in  the  popliteal 
region,  which  is  held  open  by  a  wedge  of  cork.  In  this  manner, 
by  the  insertion  of  larger  wedges  the  limb  is  gradually  straight- 
ened from  day  to  day  until  the  deformity  is  overcome,  or  until  a 
new  bandage  is  required.     If  the  pressure  on  the  front  of  the 


432 


OBTEOPEDIC  SUBGEBT. 


Fig.  297 


femur,  when  the  leverage  is  exerted,  becomes  painful,  a  part  of 
the  padding  is  removed. 

In  the  treatment  of  older  subjects  greater  force  may  be  em- 
ployed by  means  of  osteoclasts.  One  of  the  best  machines  of  this 
type  is  the  Bradford-Goldthwait  genuclast  (Fig.  297).  The 
more  violent  methods  should  not  be  employed  during  the  active 
stages  of  the  disease;  and  whenever  considerable  force  is  re- 
quired in  young  subjects  the  possibility  of  separating  the  epi- 
physis of  the  femur,  forcing  it  backward,  and  thus  pressing 
upon  the  popliteal  vessels,  should  be  borne  in  mind.    In  fact  in 

all  cases  in  which  deformity  has 
been  corrected  one  should  assure 
oneself  by  subsequent  examination 
that  the  circulation  of  the  extremity 
is  not  impaired. 

Mechanical  Treatment. — The  most 
efficient  mechanical  appliance  for 
the  treatment  of  tuberculous  disease 
at  the  knee  is  the  Thomas  knee 
brace.  This  consists  of  two  lateral 
uprights  which  support  the  limb  on 
either  side,  terminating  below  the 
foot  in  a  crossbar  shod  with  leather 
or  rubber,  which  serves  as  a  stilt, 
and  above  in  a  ring  that  fits  the 
upper  extremity  of  the  thigh,  and 
supports  the  weight  of  the  body. 
The  brace  is  made  of  iron  wire  from 
three-sixteenths  to  three-eighths  of 
an  inch  in  thickness.  The  ring  is 
The  Bradford-Goidthwait  genu-   ^f   ^^   irregular   ovoid   shape,   flat- 

clast  for  the  correction  of  flexion  ,         f  i     i     i     i  •     i 

tened  m  front,  expanded  behind 
and  wider  on  the  inner  than  on  the 
outer  side  (Fig.  298).  This  ring 
is  welded  to  the  uprights  at  a  lateral 
and  antero-posterior  inclination. 
The  lateral  inclination  forms  an 
angle  with  the  inner  bar  of  135  de- 
grees (Fig.  300),  the  antero-posterior  inclination  forms  an 
anterior  angle  of  145  degrees  (Fig.  298)  with  the  same  upright, 
which  is  set  upon  the  ring  at  a  point  slightly  in  advance  of  its 
fellow.     The  objects  of  the  shape  of  the  ring  and  of  its  inclina- 


deformity  and  subluxation  at  the 
knee.  Counterpressure  is  ap- 
plied over  the  lower  extremity  of 
the  femur.  Subluxation  is  pre- 
vented during  the  forcible  cor- 
rection by  means  of  the  screw  and 
strap  beneath  the  head  of  the 
tibia,  by  which  it  is  drawn  for- 
ward. 


TUBEBCULOUS  DISEASE  OF  THE  KNEE-JOINT. 


433 


tion  are  these :  its  anterior  part  is  flattened  to  conform  to  the 
surface  of  the  gi'oin;  its  posterior  segment  is  expanded  to  ac- 
commodate the  thickness  of  the  buttock ;  the  antero-posterior  in- 
clination adjusts  it  to  the  tuberosity  of  the  ischium.  The  lateral 
inclination  follows  the  line  of  Poupart's  ligament  from  the  inner 
to  the  outer  bar,  which  in  order  to  assure  better  support  and  less 
pressure,  rises  above  the  level  of  the  trochanter  major. 


Tig.  298. 


Fig.  299. 


The  Thomas  knee-splint,  showing 
the  inner  bar  B  placed  farther  to  the 
front  than  the  outer  bar  C ;  A  is  the 
lowest  part  of  the  ring;  upon  this 
rests  the  tuberosity  of  the  ischium. 


The  ring  of  the  Thomas  knee-splint 
after  padding.     (Ridlon.) 


The  ring  is  made  somewhat  larger  than  the  thigh  to  allow  for 
padding  with  felt.  This  should  be  thicker  on  the  inner  and 
posterior  surface,  where  the  weight  is  borne,  than  on  the  ante- 
rior and  outer  part.  The  padded  ring  is  then  smoothly  covered 
with  basil  leather.  As  used  at  the  Hospital  for  Ruptured  and 
Crippled,  the  brace  is  made  from  two  to  three  inches  longer  than 
the  leg,  to  serve  as  a  stilt  like  the  hip  splint.  To  the  foot-piece 
two  straps  are  attached  on  either  side  to  provide  for  traction  on  the 
limb  and  to  hold  the  brace  securely  in  its  place.  A  band  of  leather 
28 


434 


OBTEOPEDIC  SUSGEBY. 


is  drawn  between  the  bars  at  the  npper  third  and  another  at  the 
lower  third  of  the  brace  to  serve  as  supports  for  the  thigh  and 
calf,  i\.dhesive  plasters,  reaching  from  the  knee  to  the  ankle, 
provided  with  buckles  above  the  malleoli,  having  been  applied, 
the  ring  is  pushed  firmly  against  the  perineum  and  is  held  in 
position  by  buckling  the  straps  to  the  traction  plasters  with  as 
much  tension  as  the  comfort  of  the  patient  will  permit.  The 
thigh  and  leg  supports  should  fit  the  parts  perfectly;  the  knee 

Fig.  300. 


Thomas  knee-splint. 
Showing  the  front  of  the  ring. 


Showing  the  back  of  the  ring. 
(Ridlon.) 


is  then  fixed  in  its  place  by  a  bandage  drawn  about  it  and  the 
lateral  bars.  Ankle  and  heel  straps  complete  the  adiustment 
(Fig.  301). 

In  cases  in  which  the  joint  is  sensitive  and  in  Avhieh  there  is 
a  tendency  to  deformity  the  entire  limb  is  in  addition  enclosed 
in  a  light  plaster  bandage,  so-called  "  skin  fitting,"  applied 
directly  upon  a  cotton  flannel  bandage. 

If  the  brace  is  attached  by  means  of  the  adhesive  plaster 
straps,  a  certain  degTee  of  traction  is  assured,  together  with 
additional  accuracy  of  adjustment;  and  by  the  traction  and  by 
the  direct  pressure  on  the  knee  the  slighter  degrees  of  deformity 
may  be  reduced  without  discomfort.    In  acute  cases  preliminary 


TUBEECULOUS  DISEASE  OF  THE  KNEE-JOINT.  435 

rest  in  bed  is  advisable,  and  criitcbes  may  be  employed  in  the 
early  stages  of  ambulatory  treatment.  But  during  the  greater 
part  of  the  disease  the  brace  serves  as  a  perineal  crutch  and  by 
the  use  of  bandage  pressure  from  before  backward,  or  toward 
one  or  the  other  upright,  flexion  or  lateral  distortion  of  the  limb 
may  be  corrected  during  the  course  of  treatment.  This  brace 
may  be  used  in  the  treatment  of  very  young  children  if  it  is 
carefully  fitted  and  if  the  parts  are  kept  clean  and  dry,  and  it  is 
an  effective  brace  for  all  ages,  and  for  all  conditions  of  disease. 

The  Caliper  Brace.- — The  traction  may  be  discarded  and  the 
brace  may  be  held  in  position  by  a  shoulder  band,  or  it  may  be 
used  as  a  so-called  caliper  splint.  In  this  form  it  was  almost 
exclusively  employed  by  Mr.  Thomas  in  his  later  practice  and  at 
the  present  time  by  Ridlon,^  the  long  brace  being  used  simply  for 
a  bed  splint.  As  a  caliper  brace  the  two  bars  are  cut  off,  turned 
directly  inward  at  a  right  angle,  and  are  inserted  into  a  steel 
tube,  which  is  passed  through  the  heel  of  the  shoe.  The  bars  are 
made  slightly  longer  than  the  limb,  so  that  the  patient's  heel  is 
lifted  nearly  an  inch  from  the  inside  of  the  shoe  when  walking ; 
thus,  the  jar  of  impact  with  the  ground  is  prevented.  The  brace 
is  fixed  in  position  by  a  leather  band  beneath  the  knee  and 
another  beneath  the  calf,  and  the  limb  is  held  extended  by  pres- 
sure pads  applied  to  the  thigh  and  leg,  as  illustrated  (Fig.  302). 
Ridlon  uses  the  brace  to  reduce  deformity  by  direct  pressure 
backward  on  the  knee  by  means  of  bandages,  opiates  being  given 
to  relieve  pain. 

Other  braces  may  be  employed,  for  example,  the  traction  hip 
brace,  but  as  the  Thomas  brace  answers  every  requirement,  it 
seems  unnecessary  to  describe  others  in  this  connection.  The 
plaster  splint  is  unsatisfactory  particularly  in  the  treatment  of 
children  because  it  does  not  hold  its  place.  To  make  it  eifective 
as  a  splint  it  must  either  include  the  pelvis  or  the  foot.  It  is 
therefore  unsuitable  as  a  routine  appliance. 

Accessory  Treatment. — The  accessories  to  protective  treatment, 
which,  of  course,  includes  the  proper  attention  to  the  general 
condition  of  the  patient,  are  local  applications,  injections,  and 
venous  stasis.  They  are  classed  as  accessories  because  none  of 
them  is  essential  to  successful  treatment. 

The  local  application  of  cautery,  applied  at  intervals  of  a 
week,  or  less,  may  add  to  the  comfort  of  the  patient  and  stimulate 
the  reparative  processes.     The  X-ray  appears  to  act  in  a  some- 

^  Transactions  American  Orthopedic  Association,  vol.  vi. 


436 


OBTHOPEDIC  SUBGEBY. 


Fig.  301. 


what  similar  manner ;  it  relieves  pain,  and  in  most  instances  the 
infiltration  of  the  tissues  becomes  less  marked. 

Ichthyol  ointment  of  a  strength  of  about  40  per  cent,  relieves 
pain  and  local  congestion  in  certain  instances.  Firm  com- 
pression bv  means  of  a  flannel 
bandage  or  by  the  adhesive  plas- 
ter strapping  is  of  value,  especially 
in  the  infiltrating,  "boggy"  type 
of  disease.  The  knee  is  the  joint 
into  which  injections  may  be  made 
most  easily.  Such  injections  are 
more  likely  to  be  of  service  in  the 
synovial  than  in  the  osteal  type  of 
disease.     (See  page  263.) 

Bier's  treatment  by  passive  con- 
gestion may  be  easily  applied  and 
its  efl^ects  should  be  tested.  The 
limb  up  to  the  joint  is  firmly 
bandaged  by  a  flannel  bandage.  A 
rubber  band  is  then  applied  imme- 
diately above  the  joint  with  suffi- 
cient tension  to  retard  the  return 
of  the  venous  blood.  The  joint 
then  becomes  swollen  and  con- 
gested. The  congestion  is  applied 
for  an  hour  or  more  at  a  time, 
once  or  twice  daily.  Passive  con- 
gestion apparently  increases  the 
stability  of  the  granulation  tis- 
sue and  its  further  transforma- 
tion to  fibrous  tissue.  (See  page 
264.) 
Treatment  during  Convalescence. — During  the  active  stage  of  the 
disease  the  brace  must  be  worn  day  and  night.  During  the 
stage  of  recovery  it  may  be  used  as  a  caliper  and  finally 
shortened  so  that  the  limb  may  support  weight  and  may  be  re- 
moved at  night  to  jDermit  motion  at  the  knee.  Later  a  form  of 
walking  brace  (Fig.  205)  permitting  limited  motion  at  the 
knee  may  be  of  service ;  but  this  is  not  an  essential  in  treatment. 
If  slight  knock-knee  remains  after  recovery,  it  may  be  over- 
come by  the  use  of  a  Thomas  knock-knee  brace,  which  will  also 


4 

^ 

^ 

) 

A- 

> 

.  ,W^ 

-    a 

M 

1 

\j: 

1 

^1 

The  Thomas  knee-brace. 


TUBEBCULOUS  DISEASE  OF  THE  KNEE-JOINT. 


437 


Fig.  302. 


serve  as  a  protection  to  the  weak  joint.  The  indications  of  cure 
have  been  discussed  under  hip  disease.  In  brief,  when  sufficient 
time  has  elapsed  to  permit  of  natural  cure ; 
when  there  have  been  no  symptoms  of 
active  disease  for  months ;  when  muscular 
spasm  has  disappeared,  one  may  tenta- 
tively remove  the  brace  in  the  manner  de- 
scribed. But  any  symptom  of  disease,  and 
particularly  increasing  limitation  of  the 
range  of  motion,  or  a  tendency  toward  de- 
formity, which  resists  the  manipulative 
correction  that  must  always  be  employed 
in  the  after-treatment  of  stiffened  joints, 
indicates  the  necessity  for  continued  pro- 
tection. If  anchylosis  is  present,  super- 
vision and  occasional  corrective  treatment 
are  usually  required  during  the  period  of  ni//  | 

growth  to  assure  final  symmetry. 

Complications. — Extra-articular    Disease.  I^lli 

- — In  certain  cases,  especially  in  young 
children,  the  disease  about  the  epiphyseal 
cartilage  of  the  femur  or  of  the  tibia  may 
find  its  way  to  the  exterior  before  it  in- 
vades the  joint.  This  fortunate  course  is 
indicated  by  local  sensitiveness  and  swell- 
ing over  one  of  the  condyles  of  the  femur 
or  about  the  head  of  the  tibia.  In  such 
instances  the  thorough  removal  of  the  dis- 
ease is  indicated,  or  if  a  Roentgen  picture 
shows  that  the  disease  is  accessible  even 
though  it  is  not  immediately  below  the 
surface,  an  exploratory  operation  may  be 
advisable.  An  incision  is  made,  usually 
over  the  internal  condyle  of  the  femur. 
The  periosteum  is  raised  and  a  portion  of 
the  cortex  is  removed  in  order  to  expose 
the  spongy  bone  on  either  side  of  the  epi- 
physeal cartilage. 

In  many  instances  an  area  of  softening 
will  be  found.  This  must  be  thoroughly 
removed.  The  cavity  may  be  treated  with 
pure  carbolic  acid  or  the  cautery,  or  filled 


The  caliper  splint.  E, 
the  ring  around  the 
upper  part  of  the  thigh. 
A,  pad  for  backward 
pressure.      B,     bandage. 

C,  bandage.  F,  leather 
sling  for  support  at 
the   back    of    the    limb. 

D,  a  strip  of  bandage 
fastening  together  the 
pressure  pads  to  pre- 
vent slipping  and  con- 
sequent loss  of  pressure. 
(Ridlon  and  Jones.) 


438  OBTHOPEDIC  SUEGEBY. 

witli  iodoform  mass  and  the  wound  is  tlien  closed.  In  favorable 
cases  prompt  operative  intervention  may  cut  short  the  course  of 
the  disease. 

Abscess. — Abscess  is  present  as  a  complication  in  about  one- 
third  of  the  cases  that  have  received  efficient  protection,  and  in 
a  larger  percentage  of  those  in  which  treatment  has  been 
neglected. 

It  was  present  in  51  per  cent,  of  Koenig's  cases^  and  in  47  per 
cent,  of  three  hundred  final  results  reported  by  Gibney.^  At 
the  knee,  as  at  other  joints,  the  infected  abscess  is  the  most 
dangerous  comjilication  of  the  disease,  as  is  illustrated  by 
Koenig's  statistics : 

Death-rate  in  cases  Trithout  abscess 25  per  cent. 

Death-rate  in  cases  vrith.  abscess 46  per  cent. 

Although  in  many  instances  abscess  indicates  an  extensive  and 
destructive  disease  of  the  bone,  yet  the  exhausting  suppuration 
that  is  an  indirect  cause  of  death  is  suppuration  from  infected 
areas  in  the  thigh  and  leg,  which  may  have  little  direct  relation 
to  the  extent  of  the  original  disease.  It  should  be  the  aim  in 
treatment  to  prevent  this  burrowing  of  fluid  after  the  capsule 
has  been  perforated,  and  to  prevent  overdistention  of  the  capsule 
even,  in  order  to  lessen  the  macerating  effect  of  the  tuberculous 
fluid  upon  the  cartilages.  When  the  fluid  within  the  joint  is  of 
considerable  amount,  and  when  it  is  increasing  in  quantity,  it 
may  be  removed  by  aspiration,  or  a  better  procedure  is  to  incise 
the  capsule.  This  will  permit  thorough  removal  of  its  fluid  and 
solid  contents,  after  which  the  opening  may  be  closed  with 
sutures. 

Tuberculous  abscess  which  has  perforated  the  capsule  may  be 
treated  in  the  same  manner,  or  it  may  be  drained  subsequently, 
according  to  the  indications.  Unless  the  abscess  is  infected 
careful  bandaging  of  the  thigh  and  leg  should  prevent  bur- 
rowing. 

Synovial  Tuberculosis. — In  the  forms  of  synovial  tuberculosis 
that  resemble  chronic  synovitis  the  fluid,  if  the  quantity  is  large, 
may  be  evacuated  by  an  incision  in  the  capsule.  This  should  be 
of  sufficient  size  for  inspection — ^masses  of  fibrin  and  hypertro- 
phied  and  diseased  tissue  should  be  removed.  Afterward  the 
interior  of  the  joint  may  be  treated  with  an  application  of  a 
strong  solution  of  chloride  of  zinc  or  pure  carbolic  acid.     The 

^Loc.  cit. 

^American  Journal  of  the  Medical  Sciences,  October,  1893. 


TUBEBCULOUS  DISEASE  OF  THE  KNEE-JOINT.  439 

wound  should  then  be  closed  and  a  plaster  support  should  be 
applied.  By  the  operative  treatment  repair  is  stimulated  and 
adhesions  form  which  lessen  the  capacity  of  the  capsule.  Later 
a  protective  brace  should  be  worn  to  guard  the  joint  from  sudden 
twists  and  strains  and  to  limit  the  range  of  motion  within  the 
painless  art  (Fig.  205).  The  adhesive  plaster  strapping  may  be 
employed  in  cases  of  this  class  with  gTeat  advantage.  It  is  in 
this  type  of  disease  that  passive  congestion  is  most  effective. 
The  same  is  true  of  the  injection  of  iodoform  emulsion  or  other 
remedies  of  this  class.  Theoretically,  such  treatment  should 
hasten  repair,  should  modify  the  infectious  quality  of  the  tuber- 
culous fluid  and  lessen  the  danger  of  infection  with  pyogenic 
germs  . 

Operative  Intervention. — Arthrectomy — When,  as  in  excep- 
tional cases,  the  disease  is  jDrogressive  and  shows  no  tendency 
toward  recovery,  and  particularly  if  an  infected  abscess  com- 
municating wiih.  the  joint  makes  efficient  drainage  difficult,  the 
operation  of  arthrectomy  may  be  indicated. 

An  Esmarch  bandage  having  been  a^^plied,  the  joint  is  thor- 
oughly exposed  by  lateral  or  by  an  anterior  incision  passing 
below  the  patella,  and  all  the  diseased  tissue  is  removed  ;  that  in 
the  soft  parts  is  cut  away,  and  foci  in  the  bone  are  excavated 
with  the  chisel  and  scoop.  If  infection  be  present  the  joint  may 
be  packed  with  gauze,  the  leg  being  fixed  in  the  position  of 
flexion ;  but  in  other  instances  the  wound  is  closed  with  or  with- 
out drainage  as  may  seem  advisable.  In  a  large  proportion  of 
cases  primary  healing  may  be  obtained.  By  the  procedure  one 
may  hope  to  hasten  repair  by  removing  the  products  of  the  dis- 
ease, but  in  all  but  exceptional  cases  the  functional  result  will 
be  anchylosis.  The  operation  has  the  advantage  over  complete 
excision  in  that  less  bone  is  removed,  and  that  the  epiphyses,  in 
part,  at  least,  remain;  thus,  the  immediate  as  well  as  the  ulti- 
mate shortening  is  less  than  after  excision. 

Results  of  Aethkectomy. — The  direct  death-rate  of  the 
operation  is  small.  In  150  cases  reported  by  Koenig  but  3 
deaths  were  attributed  to  the  operation  itself.  The  flnal  results 
in  114  of  these  cases,  in  which  the  operation  was  performed  in 
childhood,  were  as  follows : 

Patients  cured  and  living 90 

Cured  of  the  local  disease,  but  not  living  at 
the  time  of  the  investigation 10 

Practically   cured,   insignificant   fistulse    re- 
maining          2 

102  =  89.5  per  cent. 


440  OBTHOPEDIC  SUEGEBY. 

Living,  not  cured 5 

Deaths  before  the  cure  of  the  local  disease.      J7^ 

12  =  10.5  per  cent. 

Thus  in  89  per  cent,  of  the  cases  the  operation  was  successful 
as  far  as  the  cure  of  the  local  disease  was  concerned.  In  75  per 
cent,  of  the  successful  cases  immediate  cure  was  attained;  in  25 
per  cent,  fistulse  persisted  for  a  longer  or  shorter  time.  In  10 
cases  some  motion  was  retained,  but  in  the  others  anchylosis 
followed  the  operation.  In  about  YO  per  cent,  of  the  cases  the 
limb  was  practically  straight ;  in  30  per  cent,  it  was  distorted. 
This  shows  the  necessity  of  continued  supervision  and  in  many 
instances  of  protective  treatment  during  the  growing  period  in 
all  cases  in  which  anchylosis  is  present  from  whatever  cause. 

In  forty-eight  cases  in  which  the  operation  had  been  per- 
formed before  the  tenth  year,  and  in  which  the  limbs  were 
straight,  the  influence  of  the  operation  on  the  growth  was  in- 
vestigated. 

Years  elapsed    Average  shortening 

Number  of  cases                                  since  operation  in  cm. 

6    2  1 

5    3  1.6 

4   4  1 

3   5  2 

19   6-7  2 

11    8-13  2.5 

These  measurements  indicate  that  the  shortening  is  not  likely 
to  be  very  great  as  a  result  of  the  operation,  certainly  very  much 
less  than  after  complete  or  even  partial  excision  performed  at 
the  same  age. 

Excision.. — Excision  of  the  joint  in  childhood  has  been  practi- 
cally abandoned,  because  of  the  great  shortening  that  follows 
complete  removal  of  the  epiphyses,  and  because  so-called  partial 
excision — that  is,  the  removal  of  the  thin  sections  of  bone  from 
the  surfaces  of  the  femur  and  tibia,  leaving  the  cartilages — is 
usually  an  unnecessary  operation,  in  the  sense  that  disease  that 
might  be  cured  by  this  procedure  might  have  been  cured  by  con- 
servative methods. 

Early  excision  in  adult  cases  is  often  indicated  because  it  will 
assure  a  cure  of  the  disease  in  a  short  time,  whereas  mechanical 
treatment  will  at  best  require  years  of  disability  with  no  certain 
prospect  of  absolute  cure  at  the  end  of  the  period.  If,  therefore, 
the  disease  has  progressed  sufficiently  to  indicate  that  the  natural 
cure  would  result  in  anchylosis,  or  if  the  time  required  for 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT. 


441 


Fig.  303. 


natural  cure  is  of  importance  to  the  patient,  early  incision  may 
be  advised  in  the  case  of  the  adult  or  adolescent  whose  growth  is 
nearly  completed. 

The  operation  is  performed  under  the  Esmarch  bandage,  and 
the  joint  is  exposed  by  the  anterior  incision,  passing  below  the 
patella  as  in  the  operation  of  arthrectomy.  All  the  diseased  tis- 
sues including  the  patella  and 
the  capsule  are  cut  away  leav- 
ing only  the  skin.  Sections 
of  the  bones,  parallel  to  the 
articular  surfaces,  are  removed 
sufficient  in  depth  to  include 
all  the  diseased  area.  The 
sections  should  allow  the  bones 
to  be  brought  into  close  appo- 
sition and  they  should  be  fixed 
by  strong  sutures  of  catgut 
passed  through  the  anterior 
apposed  surfaces  of  the  femur 
and  tibia.  The  vessels  having 
been  ligated,  the  wound  may 
be  closed  with  or  without 
drainage,  as  may  be  indicated 
by  the  character  of  the  disease, 
a  plaster-of-Paris  dressing  is 
applied,  and  the  limb  is  raised 
to  a  perpendicular  position  so 
that  the  weight  of  the  leg  may 
be  utilized  to  assure  rest. 
Mechanical  support  is  of  serv- 
ice in  the  after-treatment  in 
lessening  the  discomfort  and  hastening  the  cure. 

Results  of  Excisioin'. — In  Koenig's  statistics  of  300  ex- 
cisions, 6  deaths  were  due  directly  to  the  operation,  and  23 
others  occurred  during  the  course  of  the  after-treatment — a  total 
of  29  (9.6  per  cent.). 

In  23  instances  amputation  was  afterward  performed  because 
of  failure  of  the  operation.  The  good  results  are  classed  by 
Koenig  as  75  per  cent.,  the  bad  as  25  per  cent.  In  193  cases 
the  jDosition  of  the  limb  in  after  years  was  investigated.  It  was 
straight  in  175,  distorted  in  18,  all  but  1  of  this  latter  group 
being  in  children.     Of  400  resections  of  the  knee  in  Bruns' 


Deformity  and  shortening  resulting  from 
excision  of  the  Imee  in  childhood. 


442  OBTHOPEDIC  SUEGEBY. 

clinic  final  results  were  ascertained  in  379  cases.     The  early 
results  were  as  follows : 

Discharged,  well    343 

Discharged  with  fistulas 29 

Amputated    I7 

Dead 17 

Not  cured   4 

Final  results : 

Well   280  "^ 

With  fistulas 3 

Dead,  but  cured  of  local  dis-  >-  Good  results  87.9  per  cent. 

ease    45 

Dead,  not  cured 3  J 

Living,  not  cured 101 

Dead,   not   cured ^  L  t->    i  nx     -.« 

Died   in   clinic 7  p^<^^  ^^^^^^^  ^^  per  cent. 

Amputated    23  J 

Curvature  of  the  limb : 

Straight    27.1  per  cent. 

Moderately    flexed    28.0  per  cent. 

Markedly    flexed 44.9  per  cent. 

Amputation.- — This  operation  is  indicated  as  a  life-saving 
measure.  When  the  disease  is  so  extensive  as  to  require  com- 
plete removal  of  the  epiphyses  in  early  childhood,  amputation  is 
the  preferable  operation,  as  the  limb,  aside  from  requiring  con- 
stant protection  to  prevent  deformity,  will  be  so  short  as  to  be  of 
little  practical  use. 

Operations  for  the  Relief  of  Final  Deformity. — In  the  majority 
of  the  cases  deformity  can  be  rectified  by  one  of  the  methods 
already  described.  If,  however,  there  is  bony  anchylosis  in  an 
attitude  of  marked  fiexion  the  limb  may  be  straightened  by 
linear  osteotomy  of  the  femur  just  above  the  joint,  supple- 
mented if  the  deformity  is  extreme  by  a  secondary  osteotomy  of 
the  tibia.  If  fiexion  deformity  is  of  long  standing,  division 
of  the  hamstring  tendons  is  often  required.  In  such  cases  the 
correction  should  not  be  completed  at  the  first  ^operation  but 
preferably  at  several  sittings  to  permit  the  adaptation  of  the  soft 
parts  and  the  bloodvessels  to  the  new  attitude.  Simple  oste- 
otomy is  to  be  preferred  to  cuneiform  osteotomy  in  young  sub- 
jects, as  no  bone  is  removed. 

Genu  valgum  may  be  corrected  by  a  similar  operation.  (See 
Osteotomy  for  Knock-knee.) 

In  certain  selected  cases  the  joint  may  be  opened  for  the  pur- 


TUBEBCULOUS  DISEASE  OF  THE  KNEE-JOINT. 


443 


pose  of  separating  the  bones  and  interposing  flaps  of  iibro- 
muscular  tissue.  Although  the  prospect  of  restoring  useful 
motion  is  slight,  it  will  at  least  serve  to  correct  deformity.  See 
Anchylosis. 

Prognosis. — The  most  important  statistical  evidence  on  the 
course  and  the  outcome  of  tuberculous  disease  of  the  knee-joint 
in  childhood  has  been  presented  by  Gibney.  The  statistics  com- 
pleted in  1892  v^ere  the  result  of  an  investigation  of  499  cases 
treated  during  a  period  of  twenty  years,  1868-1887.  In  but 
300  of  these  could  definite  information  be  obtained.^ 

Eighty-seven  per  cent,  of  the  cases  were  in  children,  and  51 
per  cent,  of  the  patients  were  less  than  five  years  of  age  at  the 
inception  of  the  disease. 

The  cases  were  divided  into  three  classes,  according  to  the 
treatment  that  had  been  followed : 

1.  The  expectant  treatment.  In  this  class  no  apparatus  had 
been  employed,  or,  if  employed,  it  had  been  inefficient. 

2.  The  fixation  treatment.  In  this  class  the  joint  had  been 
more  or  less  efficiently  splinted,  but  not  protected  from  impact 
with  the  ground. 

3.  The  protective  treatment.  In  this  class  the  joint  had  been 
splinted  and  protected  from  jar,  and  the  mechanical  treatment 
had  been  efficient. 

The  results  were  classified  as  follows : 


Total. 

Excisions. 

Amputations. 

Deaths. 

Under 

treatment. 

Cured. 

Expectant  

Fixation 

71 

190 

39 

5 
9 
0 

3 

1 
0 

3 
35 

2 

9 
31 
11 

51 
114 

Protection 

26 

300 

14 

4 

40 

51 

191 

Mortality. — The  total  deaths  in  the  300.  cases  were  40  (13.3 
per  cent.)  ;  26  of  these  were  from  causes  directly  or  indirectly 
connected  with  the  disease  (8.6  per  cent.),  viz.: 

Operative  shock 1 

Prolonged  suppuration   16 

Tuberculous  meningitis    6 

Phthisis   _3 

26 
Intercurrent   diseasee    14 

40 

^  American  Journal  of  the  Medical  Sciences,  October,  1893. 


444 


OBTHOPEDIC  SUBGEBY. 


Function.. — The  functional  results  as  regards  motion  in  the 
cases  in  which  conservative  treatment  had  been  continued  to  the 
end,  including  the  cases  still  under  observation,  242  of  300, 
were  as  follows: 


Total. 

Motion  retained. 

Anchylosed. 

60 

145 

37 

44  or  73  per  cent. 
113  or  77 
34  or  95        " 

16 

Fixation 

32 

3 

242 

191  or  79  per  cent. 

51 

Of  the  191  patients  who  retained  a  movable  joint,  74  had 
had  abscesses,  3  or  more  cicatrices  being  present  in  39. 

As  to  the  range  of  motion,  in  74  it  was  from  45  degrees  to 
normal  and  in  41  more  than  90  degrees ;  thus  30  per  cent,  of  the 
patients  retained  a  fair  range  of  motion. 

Deformity. — In  51  cases  anchylosis  was  present;  in  16  of  these 
the  limb  was  practically  straight,  in  35  it  was  flexed  more  than 
30  degrees  (69  per  cent.). 

These  statistics  again  illustrate  the  great  tendency  toward 
deformity,  when  during  the  growing  period  there  is  anchylosis 
at  the  knee  from  whatever  cause. 

In  the  191  cases  in  which  motion  was  retained  the  limb  was 
practically  straight  in  125  (65  per  cent.).  In  49  others  the 
flexion  was  less  than  25  degrees,  and  in  but  16  could  the  de- 
formity be  classed  as  bad  (8  per  cent.). 

In  10  cases  only  did  relapse  occur  after  apparent  cure. 

In  but  16  of  the  449  cases  was  there  involvement  of  other 
joints  while  the  patients  were  under  observation  (3.2  per  cent.). 
In  8  of  these  the  spine  was  diseased,  in  2  the  hip,  and  in  6, 
other  joints. 

The  influence  of  age  upon  the  death-rate  and  the  ultimate 
causes  of  death  are  illustrated  by  Koenig's  statistics,  the  death- 
rate  being  much  higher,  at  least  in  the  cases  in  early  childhood, 
than  in  this  country. 

According  to  Koenig's  statistics,  the  death-rate,  direct  and 
indirect,  from  disease  of  the  knee-joint,  was  as  follows : 


323  children  (1  to  15  years  of  age),  deaths 65  =  20  per  cent. 

225  patients  (16  to  30  years  of  age),  deaths 61  =  24  per  cent. 

68  patients  (31  to  40  years  of  age),  deaths 30  =  44  per  cent. 

74  patients  more  than  40  years  of  age,  deaths .  .  45  =  60  per  cent. 


TUBEBCULOUS  DISEASE  OF  THE  KNEE-JOINT.  445 

Causes  of  Death. 

Deaths  from  causes  not  connected  with  the 

disease     14  =  2.0  per  cent. 

Deaths  following  operations 18  =  2.5  per  cent. 

Deaths  caused  by  tuberculosis,  141  =  22.5  per  cent,  of  all  cases 

and  80  per  cent,  of  all  the  deaths. 

Tuberculosis  of  the  knee 1    ' 

Tuberculosis  of  the  lungs 94 

General  tuberculosis   30 

Tuberculous  meningitis    7 

Acute   miliary   tuberculosis 3 

Tuberculosis  of  other  parts 6 

141 

It  may  be  noted  that  16  of  the  40  deaths  in  Gibney's  cases 
were  due  to  prolonged  suppuration,  and  that  of  51  cases  still 
under  observation  26  had  been  treated  for  ten  years  or  longer, 
and  were  still  uncured.  This  indicates  that  in  a  larger  propor- 
tion of  the  cases  conservative  methods  should  have  been  supple- 
mented by  more  radical  treatment.  Still,  taken  as  a  whole,  the 
results,  although  the  mechanical  treatment  was,  in  many  in- 
stances, far  from  efficient,  are  much  better  than  any  others  that 
have  been  presented. 

On  this  evidence  the  following  conclusions  seem  to  be  justi- 
fied: The  death-rate  in  childhood  from  all  causes  should  be  less 
than  10  per  cent.  The  duration  of  treatment  is  from  two  to  five 
years.  Recovery  with  a  useful  range  of  motion,  if  the  diagnosis 
has  been  made  at  an  early  stage  and  if  efficient  mechanical 
treatment  has  been  employed,  may  be  predicted  in  50  per  cent, 
of  the  cases. 

Deformity  can  always  be  prevented  by  treatment  and  by 
supervision.  Under  favorable  conditions  radical  operations  are 
not  often  indicated,  but  when  indicated  they  should  not  be  de- 
layed too  long.  Amputation  of  the  limb  should  prevent  death 
from  prolonged  suppuration.  In  a  certain  proportion  of  cases 
the  disease  may  be  cut  short  by  early  exploratory  ojDerations  for 
the  removal  of  foci  of  disease  in  the  bone  before  the  joint  has 
become  involved. 

Although  the  benefits  of  protective  treatment  are  as  evident 
in  disease  of  the  adult  as  in  childhood,  yet  early  operation  is 
often  indicated  in  this  class,  because  of  the  necessity  for  short- 
ening the  period  of  disability,  and  because  excision  assures  a 
straight  and  useful  limb. 


CHAPTEE  X. 

NOX-TUBERCULOUS    AFFECTIOXS    AND    DEFORMITIES    OF 
THE  KXEE-JOINT. 

STRAINS  AND  INJURIES  OF  THE  KNEE  IN  CHILDHOOD. 

IxjURY  of  the  knee  in  childhood  may  cause  local  discomfort 
and  persistent  flexion  of  the  leg,  even  when  but  little  synovial 
effusion  is  present.  In  this  class  of  cases  the  application  of  a 
plaster  splint,  under  sufficient  traction  to  overcome  the  de- 
formity, is  of  service  in  placing  the  part  at  rest  and  preventing 
further  injury.  The  importance  of  treating  promptly  slight 
injuries  of  the  joints  in  childhood,  especially  in  the  class  of 
patients  predisposed  to  tuberculous  infection,  has  been  men- 
tioned already  in  the  consideration  of  hip  disease. 

Muscular  "cramp,"  a  form  of  tetanic  contraction,  induced 
possibly  by  injury  or  by  a  mild  form  of  arthritis  (toxic),  which 
fixes  the  limb  in  a  flexed  or  extended  position,  is  sometimes  seen 
in  children  of  a  susceptible  or  nervous  temperament.  The 
treatment  is  similar  to  that  of  strains. 

SYNOVITIS. 

Acute  Synovitis. — The  knee  from  its  size  and  position  is 
especially  liable  to  injury,  which  if  of  any  severity  is  usually 
followed  by  effusion  of  fluid  within  the  joint  (synovitis).  -Its 
symiptoms  are  discomfort,  swelling,  local  heat,  and  limitation  of 
motion.  The  patella  floats  when  30  c.c.  of  fluid  is  contained  in 
the  joint,  the  normal  capacity  being  about  200  c.c. 

Treatment. — Injury  and  its  attendant  synovitis  may  be  treated, 
immediately,  by  splints,  by  elevation  of  the  limb,  by  the  appli- 
cation of  ice-bags  and  the  like ;  but  after  the  acute  symptoms 
have  subsided  the  absorption  of  the  effused  fluid  is  aided  by 
functional  use  of  the  limb,  if  the  joint  is  properly  protected. 
One  of  the  most  efficient  methods  of  treatment  is  that  by  means 
of  the  adhesive  plaster  strapping  advocated  by  Cottrell  and 
Gibney.  The  entire  surface  of  the  knee,  except  a  narrow  space 
in  the  popliteal  region,  is  firmly  strapped  with  overlapping 
layers  of  adhesive  plaster,  extending  from  the  upper  third  of 

446 


NON-TUBEBCULOUS  AFFECTIONS  OF  KNEE-JOINT.       447 

the  leg  to  tlie  middle  third  of  the  thigh ;  and  over  this  a  flannel 
bandage  is  applied;  or  if  the  leg  is  swollen,  the  entire  limb 
should  be  firmly  bandaged  with  elastic  stockinette  bandage,  from 
the  toes  to  the  upper  third  of  the  thigh  in  addition  (Fig  314). 
The  adhesive  plaster  serves  as  a  support  which  permits  a  certain 
degree  of  motion,  sufficient  to  stimulate  the  circulation,  and  thus 
to  hasten  the  restoration  of  the  normal  condition.  If  greater 
compression  is  desired,  the  entire  joint  may  be  covered  with  the 
adhesive  plaster  as  suggested  by  Hoffmann.^  A  pad  of  cotton 
is  placed  in  the  popliteal  space,  a  close-fitting  stocking  leg  is 
drawn  over  the  knee,  and  about  this  circular  bands  of  plaster 
are  drawn  as  tightly  as  the  comfort  of  the  patient  will  permit. 
The  adhesive  plaster  strapping  is  renewed  from  time  to  time, 
as  the  swelling  diminishes,  and  its  use  is  continued  until  the 
symptoms  have  entirely  disappeared.  Aspiration  is  always 
indicated  if  the  tension  of  the  effused  fluid  causes  discomfort. 
If  the  synovitis  persists  and  if  the  capsule  is  thickened  so  that 
its  capacity  for  absorption  is  diminished  it  should  be  incised, 
the  contents  removed  by  flushing  with  hot  salt  solution — after- 
ward the  interior  may  be  treated  with  tincture  of  iodine  or 
carbolic  acid — the  aim  being  to  lessen  the  irritability  and  to 
stimulate  the  reparative  process. 

In  cases  of  chronic  synovitis  the  muscles  are  atrophied  and 
the  ligaments  are  relaxed.  Thus  weakness  and  discomfort  may 
persist  indefinitely  unless  the  normal  tone  is  restored  by  massage 
and  by  regulated  exercises — in  cases  of  the  more  severe  type  a 
supporting  brace  is  indicated — for  the  purpose  of  preventing 
lateral  movement  and  limiting  the  anteroposterior  range  to  the 
painless  arc  (Fig.  193). 

Chronic  and  Recurrent  Synovitis. — Chronic  synovitis  is  of 
far  greater  interest  from  the  orthopedic  standpoint  than  the 
acute  form  because  it  is  usually  symptomatic  of  some  general 
pathological  condition  or  change  within  the  joint. 

Bennet^  has  analyzed  750  cases,  the  apparent  causes  of  the 
effusion  being  as  follows : 

Local. 

1.  Internal  derangement  of  the  joint 428 

2.  Loose  bodies  in  the  joint 24 

3.  Genu  valgum   4 

^  New  York  Medical  Journal,  January  27,  1900. 
^  Lancet,  January  7,  1905. 


448  OBTHOPEDIC  SUEGEBY. 

General. 

1.  Osteoarthritis     107 

2.  Eheumatism  and  gout 30 

3.  Syphilis     42 

4.  Gonorrhoea    28 

5.  Malaria     18 

6.  Haemophilia    3 

In  56  cases  no  cause  could  be  assigned  and  13  were  instances 
of  what  he  calls  "  quiet  effusion." 

Incidental  Synovitis. — Strains  of  the  knee-joint  slight  in 
degree  may  he  induced  by  genu  valgum,  by  slipping  patella  and 
the  like,  and  discomfort  is  not  infrequently  an  accompaniment 
of  the  weak  foot.  It  may  be  stated  also  that  simple  over-weight 
or  strain,  as  for  example,  laborious  work  in  fat  subjects,  may 
induce  discomfort,  creaking  sensations,  and  slight  effusion  in 
the  joint.  In  fact,  over-weight  is  the  most  constant  of  all  the 
aggravating  causes  of  weakness  in  the  knees  of  the  character 
indicated.  Reduction  of  weight  by  proper  diet  is  therefore  aii. 
important  indication  for  treatment. 

"  Quiet  Effusion." — Painless  synovitis  at  the  knee  or  other 
joints  is  sometimes  observed  in  young  females.  It  has  apparently 
some  connection  with  menstrual  irregularities.  Recurrent  effu- 
sion of  a  similar  character  in  one  or  both  knees  is  occasionally 
seen  in  older  subjects.  Without  appreciable  cause  and  occasion- 
ally at  fairly  regular  intervals  of  from  15  days  to  a  month  or 
more  the  joint  is  filled  with  fluid,  .the  principal  discomfort 
being  the  tension.  The  swelling  persists  for  several  days  and 
disappears.  In  the  intervals  the  joint  appears  to  be  normal 
except  for  a  certain  laxity  of  the  ligaments.  Fifty-five  cases 
from  literature  have  been  collected  by  Schlesinger.-^  It  is 
classed  by  Kamp^  as  a  trophic  vasomotor  neurosis.  Thyroid 
extract  has  been  employed  in  cases  of  this  character  with  ap- 
parent benefit.^ 

In  rare  instances  primary  sarcoma  of  the  capsule  may  cause 
chronic  synovitis.  The  principal  diagnostic  points  are  the  local 
or  general  thickening  of  the  capsule  and  the  bloodstained  fluid 
obtained  on  aspiration.  The  course  of  the  disease  is  very 
chronic  and  its  malignancy  is  slight.  Thorough  removal  of  the 
capsule  with  or  without  excision  would  seem  to  be  indicated. 

One  case  has  come  under  my  observation  and  eight  others  are 
reported,  in  but  one  of  which  was  there  general  dissemination 
of  the  disease. 

^Nothnagel,  Spec.  Path.  u.  .J.  Wien.  1903.  1-27. 

^Deutsche  med.  Wochens.,  March  21,  1907. 

'  Eibierre,  Bui.  de  la  See.  Med.  des  Hop.  de  Paris,  xxvii.,  96,  1910. 


NON-TUBEBCULOUS  AFFECTIONS  OF  KNEE-JOINT.       449 

Other  forms  of  synovitis  or  joint  disease  dependent  upon 
general  constitutional  causes  or  upon  direct  infection  have  been 
considered  in  Chapter  VI. 

INTERNAL  DERANGEMENT  OF  THE  KNEE-JOINT.     (Hey.) 

Internal  derangement  signifies  sudden  interference  with  the 
function  of  the  joint  which  may  be  due  to  (a)  loose  bodies  in 
the  joint;  (&)  displacement  or  fracture  of  a  semilunar  cartilage; 
(c)  other  injury. 

Loose  Bodies  in  the  Knee-Joint.^ — Loose  bodies  in  the  knee- 
joint  may  be  composed  of  portions  of  fibrin,  fragments  of  syno- 
vial membrane,  or  bits  of  cartilage  or  bone,  and  the  like.  In  cer- 
tain forms  of  synovial  tuberculosis  and  arthritis  deformans  these 
loose  bodies  may  be  present  in  large  numbers.  From  the  thera- 
peutic standpoint,  however,  the  important  cases  are  those  in 
which  the  joint  is  otherwise  normal.  In  this  class  the  foreign 
body  is  sometimes  detected  by  the  patient  as  a  smooth,  movable 
object  on  one  or  the  other  side  of  the  patella;  but  in  many  in- 
stances the  first  sign  of  its  presence  is  interference  with  the 
function  of  the  joint.  After  a  sudden  movement  or  when  the 
knee  has  been  flexed,  as  in  the  kneeling  position,  or  without 
appreciable  cause,  severe  pain  in  the  knee  is  felt  and  the  joint 
may  be  fixed  in  the  position  of  fiexion.  By  massage,  manipula- 
tion, or  spontaneously  the  foreign  body  is  dislodged  from  be- 
tween the  surfaces  of  the  bone  and  movement  becomes  free  and 
painless,  but  discomfort  remains  for  a  time  and  in  most  in- 
stances synovial  effusion  follows.  These  symptoms  recur  at 
intervals,  and  the  disappearance  of  the  movable  body  from  its 
accustomed  place  at  such  times  may  demonstrate  its  relation  to 
the  disability. 

Displacement  of  a  Semilunar  Cartilage. — Displacement  of  a 
semilunar  cartilage  is  usually  of  traumatic  origin.  The  internal 
cartilage  is  most  often  affected.  The  displacement  is  usually 
caused  by  flexion  combined  with  outward  rotation  of  the  tibia 
upon  the  femur.  The  patient  is  unable  to  extend  the  limb,  and 
in  certain  instances  an  irregularity  may  be  detected  at  the  inner 
and  upper  border  of  the  tibia. 

To  replace,  the  cartilage  the  leg  should  be  flexed  to  the  ex- 

^  According  to  Immelmann  (Zeits.  f.  artz.  Fortbildung,  1904,  No.  5),  in 
30  per  cent,  of  normal  individuals  a  sesamoid  bone  may  be  found  beneath 
the  external  head  of  the  gastrocnemius  muscle  that  might  on  an  X-ray 
examination  be  mistaken  for  a  loose  body  within  the  joint. 

29 


450 


OBTHOPEDIC  SUJRGEEY. 


treme  limit — abducted  on  the  femur,  then  rotated  inward  and 
suddenly  extended.  In  some  instances  an  angesthetic  may  be 
required.  Displacement  of  the  semilunar  cartilage  is  usually 
followed  by  eft'usion — and  by  the  ordinary  symptoms  of  the 
sprain.     The  accident  having  once  occurred,  is  likely  to  recur; 


Fig.  304. 


Fig.  305. 


The   Gi'ifflths  brace.      (Jones.) 


the  patient  recognizing  the  character  of  the  movements  that  are 
likely  to  cause  the  displacement,  also  the  proper  manipulation 
for  its  replacement. 

In  other  instances  somewhat  similar  symptoms  may  follow 
injury  at  the  knee,  pinching  of  the  synovial  membrane,  bruis- 
ing or  fracture  of  the  cartilage,  or  a  strain  of  one  of  the  liga- 
ments within  the  joint,  being  assigned  as  causes.  In  cases  of 
this  character,  in  which  symptoms  recur  from  time  to  time,  the 
joint  becomes  weak  and  insecure,  partly  because  of  the  re- 
peated synovial  effusion  and  partly  because  of  the  muscular 
relaxation. 

Treatment. — If  the  patient  is  seen  immediately  after  the  dis- 
placement or  injury  the  limb  should  be  fixed  in  a  plaster  bandage 
for  four  weeks  or  more  to  allow  for  reattachment  of  the  displaced 
part.  Afterward  the  joint  may  be  protected  by  the  adhesive 
l^laster  strapping,   and  when  the   effusion  has   been   absorbed 


NON-TUBEBCULOVS  AFFECTIONS  OF  KNEE-JOINT.       451 

massage  and  exercises  for  strengthening  the  muscles  should  be 
employed.  The  patient  should  avoid  predisposing  attitudes  and 
should  cultivate  "  straight  walking "  in  order  to  remove  the 
strain  from  the  inner  aspect  of  the  joint. 

In  the  more  chronic  cases  in  which  the  ligaments  are  lax,  a 
brace  which  will  permit  anteroposterior  motion,  but  prevent 
lateral  mobility,  may  be  required.  The  Campbell  brace  (Fig. 
.205),  used  by  Shaffer,  is  a  light  and  effective  support  that 
interferes  little,  if  at  all,  with  the  use  of  the  limb.  Jones,  whose 
experience  has  been  large,  uses  the  Griffiths  brace  to  limit  lateral 
motion  (Fig.  304). 

If  the  diagnosis  of  displaced  or  fractured  cartilage  can  be 
verified,  and  if  it  is  the  cause  of  persistent  disability,  it  should 
be  removed.  And  the  same  may  be  said  of  isolated  foreign 
bodies  which  are  known  to  be  the  cause  of  the  symptoms. 

Under  the  Esmarch  bandage  the  joint  is  opened  by  an  incision 
about  three  inches  in  length  on  the  anterolateral  and  internal 
aspect  of  the  joint.  After  the  capsule  is  opened  the  leg  is  flexed 
to  bring  the  cartilage  into  view.-^  If  loose  it  is  then  separated 
from  its  attachments  with  a  tenotomy  knife  and  is  removed. 
The  capsule  is  then  united  with  a  fine  catgut,  the  wound  is 
closed,  and  a  plaster  bandage  is  applied.  At  the  end  of  a  week 
or  more  the  patient  may  walk  about.  At  the  end  of  a  month  the 
adhesive  plaster  strapping  may  replace  the  bandage  or  prefer- 
ably in  cases  of  long  standing  the  Campbell  brace  may  be  ap- 
plied.    Perfect  functional  recovery  is  the  rule. 

HYPERPLASIA. 

Hyperplasia  of  Fatty  Tissue  within  the  Joint — The  largest  of 
the  pads  of  fibrofatty  tissue  within  the  knee-joint  is  of  a  some- 
what triangular  form,  its  base  lying  in  the  interval  between  the 
femur  and  the  tibise,  its  apex  projecting  upward,  held  between 
the  femoral  condyles  by  the  ligamentum  patellae  and  the  liga- 
mentum  mucosum.  This  may  become  enlarged  and  sensitive  to 
motion  and  pressure.  The  patient  suffers  from  discomfort  par- 
ticularly on  changing  from  a  position  of  rest  to  activity  and 
from  creaking  sensations  or  even  interference  with  motion.  At 
times  synovitis  may  be  present  and  in  many  instances  a  resistant 
swelling  is  apparent  on  either  side  of  the  patella  and  its  liga- 
ment. 

Treatment, — If  the  symptoms  are  not  relieved  by  rest,  strap- 

^  Jones  first  flexes  the  limb  to  a  right  angle  in  order  to  avoid  movement 
when  the  joint  is  open.     Annals  of  Surgery,  Dec,  1909. 


452  OETHOPEDIC  SUPiGEEY. 

ping  or  other  conservative  treatment,  the  removal  of  the  hyper- 
trophied  tissue  is  indicated.  Sensitive  tumors  of  a  similar 
nature  may  appear  in  other  parts  of  the  joint  and  folds  or 
masses  of  hypertrophied  synovial  membrane,  the  effect  usually 
of  repeated  inflammation  may  induce  similar  symptoms.  In 
such  cases  exploration  of  the  joint,  for  the  purpose  of  ascertain- 
ing the  cause  of  the  symptoms  or  for  removal  of  the  obstructing 
parts,  is  indicated. 

BURSITIS. 

Prepatellar  Bursitis.. — Synonym Housemaid's  knee. 

Enlargement  of  the  bursa  lying  over  the  patella  and  its 
ligament  is  common  among  those  who  have  to  kneel  much  of  the 
time;  hence  the  popular  name.  Occasionally  cases  of  acute 
bursitis,  in  which  there  is  considerable  effusion  into  the  sac, 
are  seen,  and  these  are  sometimes  mistaken  for  synovitis  of  the 
knee 

Treatment.- — In  acute  cases  strapping  the  front  of  the  knee 
with  strips  of  adhesive  plaster  which  will  limit  motion  and  pro- 
vide compression  is  an  effective  treatment.  If  the  effusion  is 
■considerable  it  may  be  relieved  by  aspiration  or  incision.  In 
chronic  cases  cure  can  be  attained  only  by  the  removal  of  the 
thickened  sac. 

Pretibial  Bursitis.- — Beneath  the  ligamentum  patellar,  occupy- 
ing the  space  between  the  tendon  and  the  periosteum  of  the  tibia, 
is  the  deep  pretibial  bursa.  It  is,  according  to  the  investigations 
of  Lovett,^  as  wide  or  somewhat  wider  than  the  tendon;  its 
upper  border  is  on  a  level  with  the  joint,  its  lower  border  reaches 
to  the  tubercle  of  the  tibia,  and,  being  slightly  longer  on  the 
outer  than  on  the  inner  border,  it  is  somewhat  triangular  in 
shape.     It  does  not  communicate  with  the  knee-joint. 

Enlargement  of  this  bursa  is,  as  a  rule,  the  result  of  injury, 
but,  as  bursitis  elsewhere,  it  may  be  a  complication  of  infectious 
diseases,  rheumatism  and  the  like. 

Symptoms. — The  symptoms  are  stiffness  at  the  knee  and  pain 
on  sudden  movement,  especially  when  strain  is  exerted  on  the 
tendon  by  complete  flexion  or  extension  of  the  leg  as  in  active 
use.  The  tubercle  of  the  tibia  seems  enlarged  and  is  sensitive 
to  pressure,  and  a  swelling  on  either  side  of  the  ligament  is 
usually  evident. 

^  Boston  City  Hospital  Eeports,  1897,  8th  series. 


NON-TUBEBCULOUS  AFFECTIONS  OF  KNEE-JOINT.       453 

Treatment.. — The  affection,  if  at  all  acute,  may  be  treated  by 
relieving  the  strain  and  pressure  on  the  tendon,  by  fixation  of 
the  limb  for  a  time  in  a  plaster  bandage  or  other  form  of  splint. 
Later  the  adhesive  plaster  strapping  will  provide  sufficient  fixa- 
tion and  pressure.  The  absorption  of  the  fluid  may  be  hastened 
by  the  application  of  the  cautery.  If  the  swelling  is  persistent, 
the  fluid  may  be  removed  by  aspiration  or  incision  or  removal 
of  the  sac. 

ENLARGEMENT  OF   THE   SUPERFICIAL  PRETIBIAL  BURSA. 

A  small  bursa,  lying  upon  the  insertion  of  the  ligamentum 
patellae,  may  become  enlarged,  causing  an  apparent  hypertrophy 
of  the  tubercle  of  the  tibia  which  is  sensitive  to  pressure.  It 
may  be  treated  by  strapping  with  adhesive  plaster,  and  the 
prominent  tubercle  should  be  protected  by  some  form  of  bunion 
plaster. 

INJURY  OF   THE  TIBIAL  TUBERCLE. 

In  childhood  and  adolescence  the  tibial  tubercle,  a  tongue- 
like projection  from  the  epiphysis  of  the  tibia,  is  not  united  to 
the  shaft  and  may  be  partly  separated  from  its  attachment  by 
sudden  strain  or  contraction  of  the  quadriceps  extensor  muscles. 
The  symptoms  are  local  pain,  sensitiveness  and  apparent  en- 
largement of  the  tubercle.  The  diagnosis  may  be  confirmed  by 
X-ray  examination. 

Treatment. — The  limb  should  be  fixed  in  the  extended  posi- 
tion by  a  plaster  bandage  until  union  is  firm.^ 

BURS^  AND  CYSTS  IN  THE  POPLITEAL  REGION. 

Bursitis  of  the  sac  lying  between  the  inner  head  of  the  gas- 
trocnemius and  the  semimembranosus  muscle  may  cause  a  fluc- 
tuating swelling  on  the  inner  side  of  the  popliteal  region.  It 
may  be  treated  by  compression,  by  incision,  or  by  complete 
removal  as  may  seem  advisable.  Cysts  in  the  popliteal  region 
usually  communicate  with  the  knee-joint  and  are  complications 
of  rheumatic  or  tuberculous  disease.  In  such  cases  they  are  of 
interest  principally  from  the  diagnostic  standpoint. 

^  Osgood,  Boston  Medical  and  Surgical  Journal,  January  29,  1903. 


454  OBTHOPEDIC  SUBGEBY. 

ACQUIRED  GENU  RECURVATUM. 

Synonym. — Back  knee. 

Genu  recnrvatum,  as  the  name  implies,  is  a  deformity  in 
which  the  knee  is  habitnallv  overextended. 

Etiology. — Acquired  genu  recurvatum  may  be  a  simple  local 
deformity,  or  it  may  be  secondary  to  weakness  or  distortion  of 
other  parts.  Local  or  primary  genu  recurvatum  may  be  an 
effect  of  rhachitis,  or  of  disease  or  injury  of  the  femur  or  tibia. 
In  this  form  the  femur  may  be  curved  sharply  forward  above 
the  joint,  or  the  upper  extremity  of  the  tibia  may  be  bent  back- 
ward at  the  epiphyseal  junction,  and  flexion  may  be  limited  by 
the  obliquity  of  the  articulating  surfaces. 

More  often  the  deformity  is  secondary.  It  may  be,  for 
example,  an  effect  of  equinus,  either  congenital  or  acquired,  in 
which  the  knee  is  strained  by  the  effort  of  the  patient  to  place 
the  heel  upon  the  ground.  It  may  be  caused  by  the  use  of  a 
brace  in  the  treatment  of  hip  disease,  if  the  knee-joint  is  not 
properly  supported,  and  it  is  often  seen  also  as  a  result  of  dis- 
ease at  this  joint,  for  which  no  apparatus  has  been  employed. 
It  even  appears  in  some  instances  on  the  sound  side,  apparently 
as  a  form  of  compensation  for  the  shorter  limb  (Fig.  218).  It 
is  one  of  the  comparatively  infrequent  complications  of  disease 
at  the  knee-joint,  for  which  the  leg  has  been  supported  by  the 
brace  in  an  extended  or  overextended  position,  or  in  which  the 
growth  at  the  epiphyseal  cartilages  of  the  femur  or  tibia  has 
been  irregular.  In  rare  instances  it  is  the  direct  result  of 
traumatism,  as  when  the  limb  has  been  suddenly  forced  into  an 
overextended  position,  and  the  posterior  ligaments,  and  possibly 
the  crucial  ligaments,  also,  have  been  ruptured  or  weakened. 
It  is  most  often,  however,  an  accompaniment  of  paralysis  of  the 
posterior  thigh  muscles  or  of  the  gastrocnemius  muscle,  or  both. 
A  slight  degTce  of  overextension  at  the  knees  is  not  imcommon 
in  children  who  have  the  so-called  loose  joints  and  it  is  often 
observed  in  ataxic  subjects. 

In  many  cases  genu  recurvatum  is  combined  with  a  varying 
degree  of  knock-knee,  and  there  is  often  an  abnormal  mobility 
at  the  joint  that  allows  a  certain  amount  of  posterior  displace- 
ment of  the  tibia.  In  extreme  cases  of  this  class  there  may  be 
well-marked  subluxation. 

Symptoms. — The  symptoms,  aside  from  the  deformity,  are 
weakness  and  insecurity  caused  by  the  hyperextension  when 


NON-TUBEBCULOUS  AFFECTIONS  OF  KNEE-JOINT.       455 

weight  is  borne.  If  the  deformity  is  extreme,  the  strain  upon 
the  weakened  parts  usually  causes  discomfort.  Flexion  is  ren- 
dered difficult  because  of  the  abnormal  relation  of  the  joint  sur- 
faces and  by  the  accommodative  changes  in  the  ligaments  and 
muscles,  so  that  in  extreme  cases  the  patient  swings  the  leg  along 
in  the  extended  or  overextended  position. 

Treatment.- — If  the  recurvation  is  caused  by  deformity  of  the 
bones,  the  normal  relations  may  be  restored  by  osteotomy  of  the 
tibia  or  femur,  as  may  be  indicated.  Deformity  secondary  to 
distortions  elsewhere  may  be  treated  by  remedying  the  primary 
cause. 

Traumatic  genu  recurvatum  may  be  treated  by  fixation  in  the 
flexed  position  until  the  repair  is  complete,  afterward  by  mas- 
sage and  support  if  necessary.  The  ordinary  form  of  overex- 
tended knee,  combined  with  lateral  mobility,  must  be  supported 
by  a  brace  which  permits  only  anteroposterior  motion  to  the 
normal  limit  or  slightly  less.  Whenever  possible  massage  and 
exercises  should  be  employed. 

CONGENITAL  GENU  RECURVATUM. 

Synonym.- — Anterior  displacement  of  the  tibia. 

The  most  common  of  the  congenital  deformities  at  the  knee  is 
the  so-called  genu  recurvatum,  in  which  the  knee  is  bent  some- 
what backward ;  or,  in  other  words,  the  leg  is  hyperextended  on 
the  thigh.  The  condition  is  often  spoken  of  as  an  anterior  dis- 
location, but  there  is  no  actual  displacement,  except  in  the  ex- 
treme cases  in  which  the  tibia  may  be  turned  directly  forward 
on  the  femur,  even  to  a  right  angle  or  less.  In  the  ordinary 
cases  the  range  of  extension  is  merely  exaggerated,  while  flexion 
is  limited  or  checked,  principally  by  adaptive  shortening  of  the 
quadriceps  extensor  muscle  (Fig.  306).  In  some  cases  there 
may  be  changes  in  the  direction  of  the  articulating  surfaces  in 
adaptation  to  the  deformity  of  the  femur  and  tibia. ^ 

The  appearance  in  well-marked  genu  recurvatum  is  very 
peculiar;  it  is  as  if  the  patient's  leg  were  reversed,  for  the 
popliteal  depression  has  become  a  prominence  and  the  range  of 
overextension  seems  to  represent  normal  flexion.  In  such  cases 
the  leg  may  be  brought  to  the  straight  line,  but  greater  flexion 
is  resisted  by  the  retracted  tissues,  and  when  the  pressure  of  the 
hand  is  removed  the  leg  is  drawn  back  to  the  deformed  position 
by  the  contraction  of  the  quadriceps  extensor  muscle. 
'Delanglade,  Eevue  d'Orthopedie,  May,  1903. 


456 


OETHOPEDIC  SUBGEBY. 
Fig.  306. 


Congenital  genu  I'ecurvatum.      (HofEa.) 

Accompanying  Deformities  and  Malformations. — Genu  re- 

curvatum  is  not  infrequently  accompanied  by  varus  or  valgus 
deformity  at  the  knee,  more  often  by  the  latter,  and  by  laxity 
of  the  ligaments.  In  many  instances  the  patella  is  absent  or  is 
rudimentary,  and  not  infrequently  the  deformity  is  accom- 
panied by  malformations  or  defective  development  of  other 
•parts. 

Seventy-eight  cases  were  collected  by  Potel.^  In  37  instances 
the  deformity  v^as  limited  to  one  side ;  in  the  others  both  limbs 
were  affected.  In  50  cases  the  condition  of  the  patella  was 
noted;  in' 26  of  these  it  was  absent  or  rudimentary.  Twenty 
of  the  cases  were  accompanied  by  talipes. 

Etiology. — The  deformity  in  cases  of  simple  recurvatum  may 
be  explained  by  an  abnormal  and  fixed  position  in  utero,  and  in 
cases  seen  soon  after  birth  the  mechanism  is  clearly  shown  by 
the  habitual  attitude.  The  thighs  are  sharply  flexed  on  the 
body;  the  dorsal  surfaces  of  the  hyperextended  knees  are  in 
relation  to  the  abdomen,  while  the  feet  may  be  brought  into 
contact  with  the  face  or  trunk,  according  to  the  degree  of  de- 
formity. The  retarded  development  of  the  quadriceps  extensor 
muscle  explains  the  rudimentary  patella  which  is  often  an  ac- 
companiment of  the  deformity. 

*  Etude  sur  les  Malformations  Congenitale  du  Genon.  Lille,  1897,  Imp. 
L.  Daniel. 


NON~TUBEECULOUS  AFFECTIONS  OF  KNEE-JOINT.       457 

Treatment. — The  treatment-  of  the  hyperextended  knee  is 
very  simple.  It  consists  in  massage  of  the  atrophied  and  con- 
tracted muscles,  combined  with  more  or  less  forcible  manipula- 
tion in  the  direction  of  flexion.  If,  as  is  often  the  case,  the  leg 
seems  to  be  drawn  forward  by  spasmodic  muscular  action,  the 
methodical  massage  should  be  combined  with  the  use  of  a  simple 
posterior  splint. 

In  the  more  extreme  cases  manual  force  may  be  applied  under 
anaesthesia,  and  the  deformity  may  be  overcome  at  one  or  several 
sittings,  according  to  the  resistance  of  the  contracted  parts.  The 
limb  is  then  fixed  in  a  flexed  position  until  the  tendency  to  re- 
currence has  been  overcome.  When  the  child  begins  to  walk  a 
light  lateral  brace  may  be  necessary  to  ensure  perfect  functional 
use  of  the  joint,  as  in  many  instances  laxity  of  ligaments  and 
muscular  weakness  may  persist  for  a  long  time. 

RUDIMENTARY  OR  ABSENT  PATELLA. 

As  has  been  stated,  a  rudimentary  patella  is  a  frequent  com- 
plication of  genu  recurvatum  or  of  any  congenital  defect  or  de- 
formity of  the  knee  or  limb  that  involves  imperfect  development 
of  the  quadriceps  extensor  muscle.  In  many  cases  of  this  type 
it  is  impossible  to  distinguish  the  patella  during  the  early 
months  of  infancy,  but  later  a  minute  patella  appears  that 
slowly  increases  to  an  approximately  normal  size. 

Absence  of  patella  under  the  same  conditions  is  less  frequent, 
although  Potel  collected  one  hundred  cases  from  literature. 

Treatment. — The  treatment  of  rudimentary  patella  is  in- 
cluded in  the  massage  and  stimulation  of  the  atrophied  or  rudi- 
mentary muscle  with  which  it  is  usually  associated,  and  the 
support  that  the  weak  or  deformed  knee  may  require. 

CONGENITAL  AND  ACQUIRED  DISPLACEMENT  OF  THE 

PATELLA. 

The  patella  may  be  displaced  upward  as  a  result  of  extreme 
genu  recurvatum,  and  in  rare  instances  it  may  be  displaced  in- 
ward or  downward,  but  far  more  often  the  displacement  is  out- 
ward. Fifty  cases  of  this  form  are  recorded,  in  most  of  which 
it  was  a  complication  of  congenital  genu  valgum. 

Acquired  complete  displacement  in  which  the  patella  lies  on 
the  outer  aspect  of  the  external  condyle  is  most  often  an  accom- 


458 


OBTHOFEDIC  SUEGEBY. 


paniment  of  extreme  genu  valgum.  The  first  step  in  treatment 
must  be  to  remedy  the  distortion  of  the  limb,  but  if  the  de- 
formity is  of  long  duration  the  tissues  on  the  anterior  aspect 
will  have  become  so  shortened  that  flexion  will  be  much  limited. 

SLIPPING  PATELLA. 

This  term  is  applied  to  an  abnormal  laxity  of  the  supporting 
tissues  that  allows  occasional  displacement  of  the  patella  upon 
or  to  the  outer  side  of  the  external  condyle. 

Etiology .^ — This  disability  is  more  common  among  females 
than  males,  and  is  more  often  unilateral  than  bilateral.     The 

Fig.  307. 


Slipping  patella  of  the  left  side. 


abnormal  mobility  may  be  an  inherited  peculiarity;  it  may  be 
due  to  weakness  of  the  quadriceps  extensor  muscle,  or  to  imper- 
fect development  of  the  patella  or  of  the  external  condyle  ;  or  the 
original  displacement  may  have  been  due  to  injury.  In  many 
instances,  however,  the  predisposing  cause  is  genu  valgum,  as  a 
consequence  of  which  the  patella  is  carried  toward  the  external 
condyle.  Slight  occasional  displacement  sufficient  to  cause  dis- 
comfort is  a  not  uncommon  accompaniment  of  weak  feet,  an 
indication  as  a  rule  of  muscular  weakness  or  relaxation. 


NON-TUBEECULOUS  AFFECTIONS  OF  KNEE-JOINT.       459 

Weimuty  has  collected  66  cases.  Of  these  32  were  of  con- 
genital, 14  of  traumatic  (rupture  of  internal  ligaments),  and  20 
of  pathological  origin  (knock-knee). 

Symptoms. — If  the  slipping  of  the  patella  is  a  frequent  occur- 
rence it  causes  comparatively  little  pain,  but  when  the  parts  are 
less  relaxed  the  dis^Dlacement  is  likely  to  be  followed  by  a  certain 
amount  of  effusion  into  the  joint  and  by  the  symptoms  of  a 
sprain.  It  is  usually  the  result  of  a  misstep  or  sudden  move- 
ment when  the  thigh  muscle  is  relaxed  or  of  extreme  flexion  of 
the  leg.  As  a  rule,  there  is  a  sense  of  insecurity  and  weakness 
at  the  knee  in  those  who  are  subject  to  the  accident. 

Treatment. — The  treatment  varies  according  to  the  condition 
of  the  parts  about  the  joint.  If  the  displacement  is  the  direct 
result  of  violence  the  leg  should  be  fixed  for  a  time  in  a  plaster 
bandage,  which  may  be  replaced  by  the  adhesive  plaster  strap- 
ping or  a  knee-cap.  The  improvement  of  the  muscular  tone  by 
exercises  is  always  an  important  part  of  treatment  whether  or 
not  support  is  employed.  In  cases  in  which  the  slipping  has 
become  habitual  and  particularly  when  the  ligaments  of  the 
joint  are  much  relaxed,  a  light  brace  should  be  employed  to 
prevent  lateral  motion  and  to  limit  the  range  of  flexion  at  the 
joint,  if  this  predisposes  to  the  displacement. 

Operative  Treatment. — If  the  position  of  the  patella  that  pre- 
disposes to  the  further  displacement  is  a  consequence  of  genu 
valgum  the  rectification  of  the  deformity  will,  as  a  rule,  remedy 
the  secondary  disability.  If  the  displacement  appears  to  be 
caused  by  laxity  of  the  capsular  ligament,  as  well  as  by  the  ab- 
normal position  of  the  patella,  an  operation  for  the  purpose  of 
limiting  the  mobility  and  restoring  the  proper  relation  of  parts 
may  be  conducted  in  the  following  manner :  A  long,  curved 
incision  is  made  about  the  inner  side  of  the  knee,  the  lower  ex- 
tremity of  which  crosses  the  ligamentum  patellae.  The  skin-flap 
having  been  reflected,  the  contracted  capsule  may  be  divided 
on  the  outer  side  without  disturbing  the  synovial  membrane. 
The  patella  is  then  forced  inward  and  the  redundant  tissue  on 
the  inner  side  is  folded  and  sutured,  or  a  section  of  the  capsule 
may  be  removed,  sufficient  in  size  to  hold  the  patella  in  its  proper 
position.  As  an  additional  safeguard  the  semimembranosus 
tendon  may  be  transplanted  to  the  inner  border  of  the  ligamen- 

^  Deutsche  Zeits.  f.  Chir.,  Bd.  Ixi.  Bade,  Zeits.  f.  Orthop.  Chir.,  1903, 
Bd.  xi.,  p.  3. 


460 


OBTSOPEDIC  SVEGEPiY. 


turn  patella  as  suggested  by  Backer.^     A  more  radical  proce- 
dure is  that  of  Krogius. 

Tlie  contracted  capsule  is  first  thoroughly  divided  on  the 
outer  side  as  in  the  previous  operation  and  the  patella  is  forced 
over  to  its  normal  position.  From  the  redundant  capsule  on 
the  inner  side  a  strip  one  inch  or  more  in  width  from  the  tibia 
to  and  including  the  muscle  is  separated  from  the  synovial  sac 

Pig.  308. 


Krogius"    operation   for   displaced   patella. 

and  the  musculoaponeurotic  section  is  carried  over  the  patella  to 
fill  the  oj^ening  in  the  outer  part  of  the  capsule.  The  various 
incisions  are  then  closed  with  sutures.  In  extreme  cases  the 
tubercle  of  the  tibia,  with  the  attached  tendon,  may  be  removed 
and  reimplanted  on  the  inner  aspect  of  the  tibia,  as  suggested  by 
Wolff  and  Walsham.  The  limb  should  be  held  in  the  extended 
position  for  a  time,  and  it  should  afterward  be  supported  by  a 
brace  or  knee-cap  for  several  months.  Subsequently  massage 
and  exercise  for  restoring  the  tone  of  the  weakened  muscle 
should  be  employed. 

ELONGATION  OF  THE  LIGAMENTUM  PATELLA. 

In  certain  cases  the  ligamentum  patella  may  be  abnormally 
long,  so  that  the  patella  lies  habitually  above  its  proper  position. 
This  elonaation  mav  be  one  of  the  evidences  of  o-eneral  relaxa- 


^  Zeit.  f.  Chir..  1904.  Xo.  24. 


NON-TUBEECULOUS  AFFECTIONS  OF  KNEE-JOINT.       461 

tion  of  the  ligaments  of  the  knee,  and  thus  a  predisposing  cause 
of  the  slipping  patella  or  of  abnormal  mobility  at  the  knee-joint. 

Etiology.- — The  elongation  of  the  tendon  may  be  a  congenital 
peculiarity  or  it  may  be  acquired.  It  is  most  often  observed  as 
an  eifect  of  anterior  poliomyelitis  or  of  hemiplegia  or  para- 
plegia. 

Sjmaptoms. — -The  symptoms  of  elongation  of  the  ligamentum 
patellse,  as  distinct  from  those  of  the  general  laxity  of  the  liga- 
ments that  is  often  present,  are  weakness  and  disability,  usually 
noticeable  on  walking  up  or  down  stairs,  or  after  overexertion. 
Shaffer,  who  first  called  attention  to  the  disability  from  this 
cause,  thinks  that  it  may  be  a  predisposing  cause  of  displace- 
ment of  the  semilunar  cartilages.^ 

Treatment. — In  this,  as  in  other  forms  of  insecurity  or  of 
abnormal  mobility  at  the  knee,  a  brace  that  allows  only  antero- 
posterior motion  will,  as  a  rule,  relieve  the  symptoms.  If  the 
ligament  is  of  such  a  length  as  to  require  it,  it  may  be  shortened, 
or  the  tubercle  of  the  tibia  may  be  removed  and  implanted  at  a 
lower  point,  as  suggested  by  Walsham.^ 

OTHER   CONGENITAL  DEFORMITIES  AT   THE   KNEE. 

Congenital  displacements  are  uncommon.  As  a  rule,  they 
are  incomplete  and  are  caused  by  laxity  of  the  ligaments  and  by 
defective  formation  of  the  bones  or  other  parts.  ^ 

Snapping  Knee. — A  very  slight  form  of  partial  recurrent  dis- 
placement is  the  snapping  or  clicking  knee  not  uncommon  in 
early  infancy,  in  which  the  tibia  on  sudden  extension  of  the 
limb  springs  forward  or  rotates  outward  on'  the  femur  with  an 
audible  snapping  sound.  This  movement  appears  to  be  the  re- 
sult of  voluntary  muscular  contraction  combined  with  laxity  of 
ligaments  and  very  possibly  with  irregular  movements  of  one  or 
other  of  the  semilunar  cartilages.  In  some  instances  the  sub- 
luxation appears  to  cause  pain  or  discomfort.  The  ability  to 
displace  the  tibia  on  the  femur  by  muscular  action  is  sometimes 
noted  in  older  subjects.  In  such  cases  it  may  be  the  result  of 
injury  such  as  rupture  of  ligaments  or  irregularity  within  the 
joint.  Occasionally  the  snapping  may  be  caused  by  slipping  of 
the  biceps  tendon. 

^  Transactions  American  Orthopedic  Association,  vol.  xi. 
=  Medical  Weekly,  February  17,  1893. 

'Drehmann,  Die  Cong.  Lux.  des  Kniegeleuks,  Zeits.  f.  Orth.  Chir.,  1900, 
Bd.  vii.,  H.  4. 


462  OBTEOPEDIC  SUEGEBY. 

Treatment. — The  treatment  of  congenital  dislocation  or  sub- 
luxations of  the  knee  consists  in  reposition,  support,  and  mas- 
sage of  the  weak  part.  The  snapping  knee  may  he  supported  by 
a  flannel  bandage,  or,  in  the  more  marked  type  of  laxity  of 
ligaments,  it  may  be  fixed  for  a  time  in  a  brace.  Complete 
recovery  is  the  rule. 

Congenital  Contraction. — Slight  limitation  of  the  range  of 
extension  of  one  or  both  knees  is  not  infrequent.  As  a  rule,  it 
is  easily  overcome  by  massage  and  manipulation.  In  the  more 
extreme  cases  there  may  be  an  accommodative  forward  bending 
of  the  lower  extremity  of  the  femur,  as  in  certain  cases  in  which 
flexion  follows  anchylosis. 

General  Contractions.- — Congenital  contraction  at  the  knees 
of  a  more  marked  and  resistant  form  may  be  combined  with 
flexion  contraction  at  the  hips,  or  it  may  be  one  of  a  series  of 
contractions  at  other  joints.  In  the  latter  instance  other  con- 
genital deformities,  such  as  club-hand  or  foot,  or  evidences  of 
defective  development  are  usually  present.  For  example,  cer- 
tain joints  may  be  fixed  in  flexion  or  fixed  in  extension.  In 
some  instances  the  contraction  or  the  partial  anchylosis  appears 
to  be  due  simply  to  long-continued  fixation  in  utero,  and  to  con- 
sequent non-development  of  the  muscles.  In  others  it  appears 
to  be  a  complication  of  so-called  foetal  rhachitis. 

Treatment. — The  treatment  consists  in  regular  massage  and 
manipulation,  with  the  aim  of  increasing  the  range  of  motion. 
Deformity,  if  present,  may  be  rectified  in  the  usual  manner. 

Prognosis,^ — The  prognosis  depends  upon  the  cause  of  the  con- 
traction or  fixation.  In  most  instances,  under  careful  and  con- 
tinued treatment,  the  range  of  motion  may  be  in  great  degree 
restored. 


CHAPTEK   XI. 

DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT. 

TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT. 

Disease  of  the  ankle-joint  is  the  third  in  the  order  of  impor- 
tance, although  it  is  far  less  common  than  is  disease  at  the  knee. 

In  five  consecutive  years  1788  cases  of  tuberculous  disease  of 
the  joints  of  the  lower  extremity  were  treated  at  the  out-patient 
department  of  the  Hospital  for  Euptured  and  Crippled.  In 
54.1  per  cent,  of  these  the  hip-joint  was  affected;  in  36.2  per 
cent,  the  knee-joint,  and  in  but  9.7  per  cent,  the  ankle-joint. 

Fig.  309. 


Tuberculous  disease  of  the  ankle  and  tarsus.     A^  disease  of  the  ankle  and  sub- 
astragaloid  joints.     Bj,  cavity  in  the  os  calcis  containing  sequestrum. 

Pathology. — The  pathology  of  tuberculous  disease  at  the 
ankle  differs  in  no  essential  particular  from  that  of  disease  of 
the  hip  and  knee.  It  does  not,  therefore,  call  for  special  con- 
sideration. It  is  of  interest  to  note,  however,  that  abscess  is  a 
more  common  complication  at  this  than  at  the  other  joints. 

In  30  final  results  of  disease  at  the  ankle  reported  by  Gibney,^ 
abscess  was  present  in  25  (83  per  cent.).     In  78  final  results 
^  American  Journal  of  Obstetrics,  April,  1880. 
463 


464  OETHOPEDIC  SUEGEBY. 

reported  by  Prendlsburger^  abscess  was  present  in  68  (87  per 
cent.),  as  contrasted  with  a  percentage  of  69  and  51  at  the  knee 
and  hip,  respectively.  This  gTeater  liability  to  abscess  is  prob- 
ably apparent  rather  than  actual,  since  the  ankle-joint  is  so 
superficial  that  fluctuation  may  be  detected  here  that  would  be 
overlooked  at  the  hip,  and  because  an  opening  usually  forms 
before  sufficient  time  has  elapsed  to  permit  of  absorption. 

Situation  of  the  Disease. — Otto  Hahn^  investigated  the  cases 
of  tuberculous  disease  of  the  ankle  and  foot  treated  at  Tiibingen 
during  a  period  of  fifteen  years.  These  cases  were  704  in  num- 
ber in  685  patients,  in  19  both  feet  having  been  involved. 

In  309  of  the  cases  the  disease  was  of  the  ankle-joint.  Of 
these  51  per  cent,  were  osteal  in  origin.  The  primary  focus  was 
in  the  internal  malleolus  in  11,  the  external  in  7,  in  both  in  5. 
It  was  in  the  astragalus  in  116  eases. 

In  16  instances  the  disease  of  the  ankle  was  secondary  to  pri- 
mary infection  of  the  os  calcis,  and  in  5  cases  both  the  astragalus 
and  the  os  calcis  were  diseased. 

Of  88  cases  investigated  by  Stich^  the  ankle-joint  was  in- 
volved in  88  per  cent.,  in  45  per  cent,  the  disease  being  limited 
to  this  joint.  The  astragalo-navicular  joint  was  involved  in  29 
per  cent.,  and  the  astragalo-calcaneoid  joint  in  36  per  cent. 

Etiology. — The  etiology  of  tuberculous  joint  disease  does  not 
require  further  comment.  It  may  be  noted,  however,  that  tuber- 
culous disease  at  the  ankle  is  relatively  more  common  in  later 
childhood  and  adult  life  than  is  the  same  affection  at  the  knee 
and  hip. 

Of  1000  cases  of  disease  of  the  hip-joint,  12  per  cent,  were  in 
patients  more  than  ten  years  of  age. 

Of  1000  cases  of  disease  of  the  knee-joint,  25  per  cent,  were 
in  patients  more  than  ten  years  of  age. 

Of  339  cases  of  disease  of  the  ankle-joint,  30  per  cent,  were 
in  patients  more  than  ten  years  of  age.^ 

Of  the  339  patients  177  were  males  (52.2  per  cent.);  162 
were  females  (47.8  per  cent.).  The  disease  was  of  the  right 
ankle  in  173  cases;  of  the  left  in  166. 

^  Loc.  cat. 

^Beitrage  zur  klin.  Chir.,  1900,  Bd,  xx^-i.,  H.  2. 

2  Beit.  z.  klin.  Chir.,  Bd.  xlv.,  p.  587. 

*  Statistics  from  Hospital  for  Euptnred  and  Crippled. 


DISEASES  AND  INJUBIES  OF  THE  ANKLE-JOINT. 


465 


Age  at  Incipiency  of  Ankle-joint  Disease  in  339  Consecutive  Cases 
Treated  at  the  Hospital  for  Euptured  and  Crippled. 

1  year    or    less 5       24  vears   old 2 

^                                                        ■-       --  '            <^   3 

"  3 

" 4 

"   4 

i' 2 

i'   2 

"  ..................  0 

" 1 

" 2 

" 1 

"  0 

tt  2 

"..................  2 

" 4 

" 1 

" 1 

" 4 

ti     2 

"  ...v.......... 1 

" _1 

339 


2  years    old 

3 

4 

5 

6 

7 

8 

9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 


42 

25 

43 

26 

44 

27 

34 

28 

24 

29 

19 

30 

8 

31 

9 

32 

9 

33 

11 

34 

8 

35 

4 

36 

4 

37 

4 

40 

6 

43 

2 

44 

4 

45 

3 

46 

3 

48 

4 

50 

Age  of  the  Patients  Treated  for  Ankle-joint  and  Tarsal  Disease  at 
Tubingen.     (Hahn.) 

Males. 

1  to  10  years 45 

11  to  20  years 149 

21  to  30  years 89 

31  to  40  years 32 

41  to  50  years 37 

51  to  60  years 35 

61  to  70  years 18 

71  to  80  years 6 

81  years 1 

412 


emales 

Total 

28 

73 

91 

240 

34 

123 

28 

60 

27 

64 

26 

61 

11 

29 

1 

7 

0 

1 

246 

658 

JFour  hundred  and  twelve  of  the  658  patients  were  males  (62 
per  cent.)  ;  246  were  females  (38  per  cent.).  In  27  the  sex  was 
not  stated. 

Symptoms. — The  symptoms  are  nsnally  subacute  in  charac- 
ter, and  are  often  mistaken  for  sprain  or  rheumatism.  In  some 
instances- they  appear  to  follow  an  injury,  but  in  the  majority  of 
cases  in  childhood  no  cause  can  be  assigned.  The  ankle  becomes 
sensitive  to  sudden  movements;  the  patient  limps,  and  there  is 
complaint  of  discomfort  after  overuse  and  of  pain  at  night.  The 
limp  differs  in  character  from  that  caused  by  hip  or  knee  disease. 
The  patient  walks  with  the  limb  rotated  outward,  bearing  the 
weight  upon  the  heel  and  upon  the  inner  border,  active  leverage 
"  spring  "  being  avoided. 
30 


466 


OBTHOPEDIC  SUBGEBY. 


Primarily  the  symptoms  are  those  of  a  persistent,  somewhat 
painful  disability  at  the  ankle,  causing  stiffness,  limp,  and  at 
times  pain;  later  deformity  appears. 

Deformity. — The  primary  deformity  of  ankle-joint  disease  in 
the  subacute  cases  is  valgus,  induced  by  a  persistence  of  the 
passive  attitude.  In  more  advanced  cases  it  becomes  equino- 
valgTis,  and  when  the  limb  is  no  longer  capable  of  supporting 
weight,  but  is  held  pendent,  the  equinus  predominates. 

Fig.  310. 


Tuberculous  disease  of  the  ankle. 


The  joint  is  usually^  somewhat  enlarged.  In  some  instances 
the  swelling  is  uniform ;  in  others  it  is  localized  in  front  or 
behind  one  of  the  malleoli.  This  swelling  is  not,  as  a  rule, 
like  that  of  simple  effusion  into  the  joint,  but  the  tissues 
have  the  peculiar  elasticity  characteristic  of  thickening  and  in- 
filtration. There  is  usually  a  perceptible  increase  in  the  local 
temperature,  and  pressure  directly  upon  the  malleoli  causes  dis- 
comfort. The  voluntary  movements  of  the  joint  are  restricted, 
and  passive  movements  show  the  characteristic  reflex  muscular 
spasm,  limiting  both  dorsal  and  plantar  flexion. 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT.        467 

Subastragaloid  Disease..— If  the  astragalus  is  primarily  dis- 
eased, the  symptoms  are  usually  first  apparent  in  the  ankle-joint, 
but  in  certain  cases  the  joint  between  the  astragalus  and  the  os 
calcis  is  first  involved.  Disease  at  the  subastragaloid  joint  is 
usually  classed  as  ankle-joint  disease,  although  the  swelling  is 
most  marked  at  a  point  somewhat  below  the  malleoli  (Fig.  311). 

Fig.  311. 


Tuberculous  disease  of  the  subastragaloid  joint. 

In  this  form  forced  lateral  motion  of  the  os  calcis  causes  dis- 
comfort, and  the  range  of  adduction  and  abduction  of  the  foot 
is  restricted,  while  dorsal  and  plantar  flexion  may  be  unre- 
stricted. 

Astragalo-navicular  Disease..— If  the  disease  is  limited  to  the 
joint  the  foot  is  usually  fixed  in  an  attitude  of  persistent  ab- 
duction and  as  the  process  is  usually  of  the  subacute  type  it 
may  be  mistaken  for  rigid  weak  foot. 

Diagnosis. — The  principles  of  differential  diagnosis  of  tuber- 
culous disease  from  other  affections  have  been  considered  in 
detail  in  the  description  of  disease  of  the  larger  joints. 

In  childhood  a  chronic,  painful  disease  confined  to  a  single 


Fig.  312. 


The  epiyliyses  of  the  lower  extremities  at  the  age  of  six  years,  showing  the 
effect  of  operative  removal  of  bone  at  the  ankle-joint  for  tuberculous  disease  at 
the  age  of  three  years,  in  causing  subsequent  deformity  of  the  foot  and  shortening 
of  the  limb.  Ossification  is  present  at  birth  in  the  lower  epiphysis  of  the  tibia. 
It  begins  at  the  second  year  in  the  lower  epiphysis  of  the  fibula,  but  not  until 
the  fifth  year  in  its  upper  epiphysis. 


DISEASES  AND  INJUBIES  OF  THE  ANKLE-JOINT.        469 

joint  in  which  motion  is  limited  by  muscular  spasm,  and  in 
which  there  is  a  tendency  to  deformity,  is  almost  certainly  tuber- 
culous in  character. 

In  adult  life  also  the  same  statement  applies,  and  distin- 
guishes tuberculous  disease  from  rheumatism,  arthritis  de- 
formans, or  other  multiple  joint  diseases.  Forms  of  infectious 
arthritis  may  be  differentiated  by  the  history.  Sprains  or  other 
injury  may  be  distinguished  by  the  history  of  the  onset  and  by 
the  absence  of  local  signs  of  serious  disease.  In  weak  or  pain- 
ful flat-foot  the  symptoms  are  localized  at  the  mediotarsal  joint. 
It  should  be  borne  in  mind,  also,  that  the  pain  from  a  weak  or 
injured  foot  is  felt,  as  a  rule,  only  when  it  is  in  use;  whereas, 
in  tuberculous  disease  of  the  bone,  pain  is  common  when  the 
part  is  not  in  use,  particularly  at  night. 

Treatment. — In  disease  of  this,  as  of  other  joints,  functional 
rest  is  indicated.  This  necessitates  fixation  of  the  joint  and 
stilting  of  the  limb,  efficient  traction  being  manifestly  impos- 
sible. The  foot  should  be  fixed  in  a  light  plaster  bandage  ex- 
tending from  the  extremities  of  the  toes  to  the  upper  third  of  the 
leg,  at  a  right  angle  with  the  leg  and  in  an  attitude  of  slight  in- 
version, in  order  to  guard  against  the  tendency  toward  valgus. 
This  deformity  is  very  common  after  the  cure  of  the  disease, 
and  it  often  subjects  the  patient  to  the  additional  discomfort  o£ 
the  weak  foot. 

Reduction  of  Deformity. — If  the  foot  has  become  distorted  be- 
fore the  patient  is  brought  for  treatment,  a  plaster  bandage  may 
be  applied  in  the  attitude  of  deformity,  and  at  the  subsequent 
applications  of  the  dressing,  when  the  muscular  s]3asm  is  less- 
ened, the  malposition  may  be  reduced  by  gentle  manipulation. 
In  resistant  cases  immediate  reduction  of  the  deformity  under 
ansesthesia  may  be  advisable.  Throughout  the  entire  course  of 
treatment  the  greatest  attention  must  be  paid  to  the  attitude. 
Deformity  is  easily  prevented,  but  is  often  very  difficult  to  cor- 
rect, especially  during  the  later  stages  of  the  disease,  when  the 
tissues  are  infiltrated  and  sensitive,  and  especially  if  discharging 
sinuses  are  present. 

Other  retentive  appliances  may  be  employed,  but  they  are 
inferior  to  a  properly  ajDplied  plaster  support,  which  holds  its 
place  by  accuracy  of  adjustment,  which  most  effectively  prevents 
motion,  and  which  exercises  a  certain  degree  of  compression 
upon  and  general  support  of  the  swollen  joint.  The  bandage  is 
usually  renewed  at  intervals  of  a  month,  but  it  may  be  retained 


470  OETHOPEDIC  SUBGEBY. 

indefinitely  if  it  is  properly  protected  by  a  light  shoe  or  slipper. 
The  Bier  method  of  passive  congestion  may  be  applied  by  means 
of  a  bandage  above  the  knee.  The  adhesive  plaster  strapping 
may  be  nsed  beneath  the  plaster  bandage  if  local  compression 
and  more  comprehensive  support  is  desired. 

The  most  satisfactory  brace  to  serve  as  a  stilt  in  connection 
with  the  local  support  is  the  Thomas  brace.  Tvhich  has  been  de- 
scribed in  the  section  on  disease  of  the  knee-joint  (Fig.  309). 

"When  patients  are  treated  efficiently  the  discomfort  or  incon- 
venience attending  the  disease  is  slight.  As  a  rnle.the  swelling 
of  the  joint  becomes  more  localized  and  finally  an  abscess  ap- 
pears beneath  the  skin.  It  is  then  advisable  to  remove  the  fluid 
and  other  contents  by  means  of  a  simple  incision.  In  most  in- 
stances a  sinus  persists  for  a  time.  If  the  discharge  is  slight, 
the  part  may  be  dressed  with  ichthyol.  balsam  of  Peru  or  other 
application,  and  the  whole  enclosed  again  in  the  plaster  band- 
age ;  or,  if  it  be  more  profuse,  an  opening  may  be  made  and  the 
dressing  applied  outside  the  plaster  bandage.  When  the  stage 
of  recovery  is  reached,  stilting  apjjaratus  may  be  discarded,  the 
patient  being  allowed  to  bear  the  weight  on  the  foot,  protected 
by  the  jDlaster  bandage  or  other  support. 

Operative  Treatment. — Early  operation,  especially  of  a  goug- 
ing character,  involving  the  articulations  should  be  avoided. 
An  effective  operation  of  this  class  often  involves  the  sacrifice  of 
bone  that  would  be  spared  in  the  natural  cure,  and  it  entails  an 
irregularity  in  the  gTowth  and  causes  deformity  in  after-life 
that  may  be  irremediable  (Fig.  312). 

Similar  operations  in  the  treatment  of  fistute,  or  abscess, 
while  the  tissues  are  thickened  and  (edematous,  and  while  the 
disease  within  the  joint  is  active,  should  be  postponed  until  the 
process  of  repair  is  more  advanced.  During  the  stage  of  con- 
valescence, however,  cure  may  be  hastened  by  the  removal  of 
persistent  foci  of  disease,  or  sequestra  in  the  bone,  or  tuber- 
culous tracts  in  the  overlying  soft  parts. 

In  the  adult  or  adolescent,  and  in  exceptional  cases  in  child- 
hood, operative  treatment  may  l)e  indicated.  If  the  disease 
is  confined  to  the  ankle-joint,  the  removal  of  the  astragalus, 
which  is  usually  the  primary  seat  of  infection,  is  the  operation 
of  choice. 

The  operation  is  performed  under  the  Esmarch  bandage;  a 
curved  lateral  incision  is  made  passing  beneath  the  external 
malleolus  from  the  neighborhood  of  the  tendo  Achillis  to  the 


DISEASES  AND  INJURIES  OF  TEE  ANKLE-JOINT.        471 

anterior  aspect  of  the  joint.  The  lateral  and  capsular  ligaments 
I' re  divided,  after  which  the  foot  may  be  displaced  inward.  The 
astragalus  is  exposed  and  it  may  be  removed  easily  by  dividing 
the  ligaments  about  its  head  and  its  attachments  to  the  os  calcis. 
All  the  diseased  tissue  in  the  soft  parts  and  in  the  bone  must  be 
removed  thoroughly.  If  the  disease  has  not  extended  to  the 
tarsus,  and  if  it  seems  to  have  been  completely  removed,  the 
wound  may  be  closed,  but  in  most  cases  it  should  be  packed  for 
.a  time  with  gauze.  In  all  cases  the  foot  should  be  displaced 
backward  so  that  the  malleoli  may  rest  upon  the  anterior  ex- 
tremity of  the  OS  calcis.  The  after-treatment  is  conducted  as  if 
the  operation  had  not  been  performed,  support  and  fixation 
being  continued  until  it  is  evident  that  the  disease  is  cured. 

Removal  of  the  astragalus  does  not  interfere  to  a  marked  ex- 
tent with  the  function  of  the  foot,  nor  does  it  cause  noticeable 
deformity.  As  a  primary  operation,  permitting  inspection  and 
the  opportunity  for  thorough  removal  of  all  disease  in  the  neigh- 
boring parts,  it  should  always  be  performed  in  preference  to 
extensive  gouging,  which  is,  as  a  rule,  of  little  avail.  It  may  be 
mentioned  in  this  connection  that  motion  in  an  anchylosed  joint 
may  be  restored  by  the  removal  of  the  astragalus. 

Prognosis.- — Disease  at  the  ankle  is  not  only  less  common,  but 
it  is  less  dangerous  than  that  of  the  larger  joints,  because  it  is 
remote  from  important  structures,  and  because  there  is  less 
opportunity  for  the  burrowing  of  infected  abscesses.  The  dura- 
tion of  the  disease  here  is,  as  a  rule,  shorter  than  at  the  knee  or 
hip,  and  the  final  results  in  childhood  are  almost  always  excel- 
lent. Often  free  motion  is  retained  at  the  ankle,  and  even  if  the 
astragalus  be  fixed  by  disease  the  mobility  in  the  other  joints  of 
the  foot  is  sufficient  to  compensate  very  effectively  for  the  anchy- 
losis. Shortening  of  the  limb  is  of  comparatively  little  conse- 
quence. It  is  not  often  more  than  an  inch,  and  it  may  be  absent. 
The  growth  of  the  foot  is  often  considerably  retarded,  partly 
from  disuse  and  partly  because  of  the  destructive  effect  of  the 
disease  upon  the  tarsal  bones. 

In  the  30  cases  reported  by  Gibney,  treated  expectantly,  in 
which  the  mechanical  treatment  was  far  from  effective,  6 
patients  recovered  with  normal  motion;  11  with  practically 
normal  function.  In  7  there  was  good  motion.  In  6  there  was 
anchylosis,  and  in  3  persistent  valgus.  In  all  the  limb  was  effi- 
cient. In  20  instances  there  was  no  limp,  and  in  but  1  case  was 
it  marked.     In  no  instance  was  a  crutch,  cane,  or  other  support 


472  OBTHOPEDIC  SUEGEBY. 

used.  The  average  duration  of  the  disease  was  three  years  and 
three  months,  a  minimum  of  one  year,  a  maximum  of  six  years. 
There  were  2  deaths,  of  which  but  1  was  dependent  upon  the 
disease,  septicaemia  being  the  cause  assigned,  though  it  is  stated 
that  practically  all  the  bones  of  the  tarsus  were  involved.  In 
this  case  amputation  was  evidently  indicated. 

TUBERCULOUS  DISEASE  OF  THE  TARSUS. 

Tuberculous  disease  of  the  joints  of  the  foot,  not  involving 
the  ankle,  is  not  uncommon. 

In  386  of  the  704  cases  reported  by  Ilahn,  the  disease  was 
limited  to  the  foot.  In  141  cases  the  mediotarsal  joint  was  in- 
volved; in  51  of  these  the  disease  was  confined  to  this  joint;  in 
46  the  ankle  was  involved;  in  29  the  disease  extended  forward 
to  the  tarsometatarsal  articulation,  and  in  16  the  three  joints 
were  diseased.  In  Y8  cases  the  tarsometatarsal  joint  was  in- 
volved, in  33  of  which  the  disease  did  not  extend  beyond  this 
articulation. 

Distribution  among  Individual  Bones. — In  these  cases  the 
distribution  was  as  follows : 


The    astragalus 170 

The    calcaneum 200 

The  cuboid 116 

The    scaphoid 82 

The  cuneiform  bones...    86 


disease  confined  to  the  single  bone  in  8 
disease  confined  to  the  single  bone  in  87 
disease  confined  to  the  single  bone  in  18 
disease  confined  to  the  single  bone  in  2 
disease  confined  to  the  single  bone  in  8 
r  in  one-half  of  these  the  disease  was 
,,,,         ,,  ,j.Jof  the  first   metatarsal,  either  alone 

Metatarsal  bones 45;    -^       ^^  .^  connection  with  the  adjoining 

L      cuneiform  bone  or  phalanx. 

In  a  total  of  1231  cases,  including  these  and  others  reported 
by  Audry,^  Koenig,^  Mondan,^  Mlinch,^  Spengler,^  Vallas,*'' 
Czerny,'''  and  Dumont,^  the  relative  frequency  of  the  disease  in 
the  bones  of  the  foot  and  ankle  appeared  to  be  as  follows : 

Malleoli     96,  7.7  per  cent.       Scaphoid    110,  8.9  per  cent. 

Astragalus    ...291,  23.6  per  cent.  Cuneiform    bones.  109,  8.8  per  cent. 

Calcaneus    .  .  .  .339,  25.9  per  cent.      Metatarsus 110,  8.9  per  cent. 

Cuboid 154,  12.5  per  cent.       Phalanges    22, 1.7  per  cent. 

•       ^  Eevue  de  Chir.,  1891. 

=  Schmidt's  Jahrb.,  1884,  Bd.  cciv. 

^Deutsche  Chir.,  1.,  66. 

*  Deutsche  Zeits.  f.  Chir.,  1879,  Bd.  xi. 

'  Ibid.,  1897,  Bd.  xliv. 

"Deutsche  Chir.,  1.,  66. 

'  Volk.  S.  Klin.,  v..  No.  76. 

^  Deutsche  Zeits.  f .  Chir.,  1882,  Bd.  xvii. 


DISEASES  AND  INJUBIES  OF  THE  ANKLE-JOINT.        473 

In  disease  limited  to  the  astragalo-na^dcular  joint  the  swellifig 
and  sensitiveness  are  localized  in  front  of  the  ankle  on  the 
inner  side  of  the  foot.  Adduction  is  restricted,  and  the  foot  is 
often  fixed  in  an  attitude  of  persistent  abduction. 

Disease  of  other  bones  or  joints  of  the  tarsus  is  indicated  by 
the  local  swelling  and  sensitiveness. 

Treatment. — Disease  of  the  tarsus  shows  a'  marked  tendency 
to  extend  from  one  bone  to  another  until  the  entire  foot  is  in- 
volved. Consequently  if  an  early  diagnosis  is  made  of  a  dis- 
tinctly localized  process  prompt  removal  of  the  affected  bone  is 
indicated;  but  in  most  instances  the  disease  is  too  extensive  to 
permit  of  its  radical  removal.  In  such  cases  operative  inter- 
vention is  contraindicated,  and  the  treatment  by  protection  simi- 
lar to  that  employed  in  disease  of  the  ankle,  is  indicated.  In 
childhood  the  prognosis  is  very  good  even  when  the  disease  is 
extensive,  but  in  adult  life  amputation  of  the  foot  may  be  advis- 
able because  of  the  time  required  to  assure  a  natural  cure  and 
because  an  artificial  leg  provides  a  better  support  than  a  stiff 
and  sensitive  extremity.  Amputation  is  almost  always  indi- 
cated, if  there  is  co-existent  disease  of  the  lungs. 

INJURIES  OF  THE  ANKLE-JOINT. 

Sprain. — The  ankle  is,  from  its  position,  especially  liable  to 
injury;  in  fact,  the  term  "  sprain"  is  popularly  associated  with 
this  joint. 

Etiology.. — A  sprain  is  most  often  caused  by  an  unguarded 
movement,  by  which  the  foot  is  turned  suddenly  inward  or  out- 
ward, with  sufficient  force  to  injure  the  synovial  membrane,  to 
rupture  some  of  the  fibres  of  the  muscles,  to  strain  tendons  and 
tendon  sheaths,  and  even  to  rupture  ligaments.  If  the  foot  is 
twisted  inward  the  injury  is  most  marked  on  the  outer  side  of 
the  joint ;  if  outward,  on  the  inner  side  of  the  ankle.  In  the 
slighter  degrees  of  sprain  the  injury  may  be  confined  to  the 
tissues  about  the  joint,  but  in  most  instances  there  is  effusion 
within  the  capsule,  even  hemorrhage  when  injury  has  been 
severe. 

Symptoms. — The  immediate  sympfoms  of  sprain  are  pain, 
often  intensie,  of  a  throbbing  character,  swelling,  heat,  and  in 
many  instances  discoloration  of  the  surrounding  jjarts,  even 
extending  over  the  leg  and  foot. 

Treatment.- — If  an  opportunity  for  immediate  treatment  is 


474  OPiTHOPEDIC  SUEGEBY. 

offered,  the  swelling  and  the  effusion  of  blood  may  be  restrained 
hj  wrapping  the  limb  from  the  toes  to  the  knee  with  a  thick 
layer  of  absorbent  cotton  and  bandaging  it  firmly.  As  much 
compression  being  exercised  as  the  comfort  of  the  patient  will 
allow^  the  thick  covering  restrains  motion  and  the  elastic  pres- 
sure prevents  swelling.  The  stockinette  bandage  (Fig.  314)  may 
be  used  for  the  same  purpose.  If  the  injury  has  been  severe  and 
if  the  part  is  very  sensitive  to  motion  or  jar,  the  joint,  having 
been  protected  with  cotton,  may  be  fixed  in  a  light  plaster 
bandage.  This  may  be  cut  down  the  front  to  permit  massage 
of  the  foot,  ankle,  and  leg,  which  is  of  great  service  in  hastening 
the  absorption  of  the  effusion. 

The  use  of  hot  air,  hot  and  cold  water,  and  static  electricity, 
and  the  like  are  of  service  also. in  relieving  the  discomfort  and 
more  especially  in  stimulating  the  circulation,  upon  which  repair 
depends. 

By  far  the  most  effective  treatment  during  the  stage  of  re- 
covery and  as  an  immediate  application  for  sprains  of  slighter 
degree,  is  the  adhesive  plaster  strapping  which  has  been  popu- 
larized by  Gibney.  His  method  is  as  follows  :  Strips  of  adhesive 
plaster  about  three-quarters  of  an  inch  in  width  and  from  nine 

Fig.  313. 


A  method  of  applying  adhesive  plaster  strapping  for  sprain  of  the  ankle. 

to  eighteen  inches  in  length  are  prepared.  A  long  strip  is  placed 
with  its  centre  beneath  the  heel,  and  the  two  ends  are  carried 
upward  over  the  malleoli,  to  a  point  at  the  junction  of  the  mid- 
dle and  lower  thirds  of  the  leg.  A  second  strip  is  placed  at  the 
posterior  extremity  of  the  heel,  and  the  two  ends  are  carried 


DISEASES  AND  INJUBIES  OF  THE  ANKLE-JOINT.        475 

forward  somewhat  beyond  the  tarsometatarsal  junction  on  either 
side.  Another  strip  is  then  placed  by  the  side  of  the  iirst,  and 
the  fourth  by  the  side  of  the  second,  until  the  entire  ankle  is 
smoothly  covered,  except  for  a  space  about  two  inches  in  width 
directly  on  the  front  of  the  ankle.  One  takes  particular  care 
to  make  the  plaster  fit  well  about  the  malleoli  and  reinforces  it 
at  the  points  of  greatest  sensitiveness.  A  light  bandage  is  then 
applied  and  the  patient  is  encouraged  to_use  the  foot  in  walking. 
The  plaster  may  be  applied  in  a  variety  of  ways ;  a  satisfactory 
method  is  as  follows,  after  the  preliminary  massage  for  the  pur- 
pose of  reducing  the  swelling:  One  end  of  a  strip  of  adhesive 
plaster  about  three  feet  long  and  three  inches  wide  is  applied 
to  the  lateral  aspect  of  the  leg  just  below  the  knee-joint;  it  is 

Fig.  314. 


The  stockinette  bandage.     An  effective  means  of  reducing  swelling  and  protecting 
the   sensitive   joint   to   be   used   in    combination   with   massage. 

carried  down  the  side  of  the  leg  over  the  malleolus,  beneath  the 
heel  and  arch,  and  up  the  other  side  to  a  point  opposite  the  be- 
ginning where  it  is  fixed  by  a  circular  band  about  the  calf.  If 
the  sprain  is  of  the  outer  side  of  the  ankle,  sufficient  tension  is 
made  upon  the  outer  half  of  the  plaster  to  hold  the  foot  slightly 
abducted.  If,  as  is  more  common,  the  sprain  is  of  the  inner 
side,  the  inner  half  is  drawn  firmly  beneath  the  arch,  carrying 
the  foot  toward  inversion  so  that  all  strain  may  be  removed 
from  the  sensitive  part.  This  band  of  plaster  is  reinforced  by 
one  or  more  so  that  the  lateral  aspect  of  the  ankle  is  completely 
covered.  And  in  addition  the  entire  ankle  is  then  enclosed  with 
narrow,  overlapping  strips  which  cover  all  the  tissues  well  be- 
yond the  sensitive  area.     The  foot  and  leg  are  then  bandaged 


476  OETHOFEDIC  SUEGEEY. 

to  assure  the  adhesion  of  the  plaster.  When  the  joint  is  firmly 
held  bv  the  supporting  plaster  the  patient  can,  as  a  rule,  walk 
with  comfort;  and  he  is  encouraged  to  do  so,  for  functional  use, 
provided  it  does  not  cause  additional  injury,  is  the  most  effective 
stimulant  of  the  circulation;  thus  the  patient  applying,  as  it 
were,  an  automatic  massage,  cures  himself. 

As  the  swelling  subsides  the  plaster  strapping  wrinkles,  and  it 
must  be  renewed,  about  three  applications  being  required,  as  a 
rule,  the  last  of  which  is  allowed  to  remain  until  all  of  the  symp- 
toms have  disappeared.  Vigorous  massage  before  applying  the 
new  dressing  is  of  service  in  hastening  the  cure.  It  is  perhaps 
needless  to  state  that  a  preliminary  shaving  of  the  part  will  add 
to  the  comfort  of  the  patient. 

Chronic  Sprain. — A  chronic  sprain  may  be  the  result  of  an 
inefficiently  treated  acute  injury,  in  which  an  improper  atti- 
tude originally  assumed  to  spare  the  sensitive  part  finally  be- 
comes habitual.  In  other  instances  persistent  disability  may  be 
the  result  of  fixation  of  the  joint  for  too  long  a  time  in  splints. 
Such  disuse  causes  atrophy  of  the  muscles  and  of  the  bones  as 
well,  while  the  eft'used  material  within  and  without  the  joint 
remains  because  of  the  imperfect  circulation.  The  same  dis- 
ability may  follow  simple  disuse  of  the  injured  part.  It  is  more 
often  observed  in  nervous  individuals  who  exaggerate  the  im- 
portance of  the  injury  and  the  discomfort  that  it  causes.  In 
such  cases  the  limb  may  be  discolored  by  venous  congestion,  the 
foot  may  be  oedematous  and  the  movements  may  be  limited  by 
adhesions  or  by  muscular  adaptation  to  the  habitual  attitude. 

In  other  instances  the  original  injury  may  have  caused  a 
slight  subluxation  of  the  astragalus,  sufficient  to  throw  the  foot 
into  an  attitude  of  abduction,  in  which  it  has  become  fixed  by 
the  secondary  changes  in  the  muscles  and  ligaments.  In  some 
cases  of  this  class  the  original  sprain  was  at  the  mediotarsal  or 
at  the  subastragaloid  joint,  and  its  effect  has  been  traumatic 
weak  foot.  It  may  be  stated,  also,  that  many  of  the  so-called 
sprains  of  the  ankle  are  simply  injuries  of  a  weak  foot,  a  dis- 
ability to  which  the  treatment  should  be  directed.  (See  the 
Weak  Foot.) 

Treatment.. — Treatment  must  be  conducted  with  the  aim  of  re- 
storing the  normal  range  of  motion  and  so  supporting  the  part 
that  normal  functional  use  may  be  permitted.  If  adhesions 
have  formed  and  if  the  foot  is  persistently  held  in  an  abnormal 
attitude,   forcible  manipulation  under  anaesthesia  may  be  re- 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT.        477 

quired  as  a  preliminary  treatment,  followed  by  fixation  for  a 
time  in  a  plaster  bandage,  in  the  attitude  directly  opposed  to 
tbat  which  has  been  habitual.  In  this  class  of  cases  the  habitual 
attitude  is  usually  one  of  equinovalgus ;  the  foot  should  be  fixed 
for  a  time,  therefore,  in  a  plaster  bandage  in  a  position  of  ex- 
treme varus,  at  a  right  angle  with  the  leg,  and  upon  it  the 
patient  is  encouraged  to  bear  his  weight  both  in  standing  and 
walking.  When  all  discomfort  has  disappeared,  a  support, 
usually  a  light  leg  brace  to  prevent  lateral  motion,  and  if  the 
arch  is  depressed  a  foot  plate  also,  should  be  worn  for  a  time. 
The  most  effective  curative  agent  is  functional  use,  but  massage, 
hot  air,  passive  manipulation,  and  exercises  are  valuable  ac- 
cessories. 

Injuries  of  this  class  are  very  amenable  to  treatment,  con- 
ducted with  the  aim  of  restoring  normal  function,  if  proper  sup- 
port is  provided  during  the  period  of  pain  and  weakness. 

Fracture  of  the  Tarsal  Bones. — If  the  injury  has  been  severe, 
especially  a  fall  from  a  height,  fracture  of  the  tarsal  bones 
should  be  considered  as  a  possible  complication  of  the  sprain. 
One  should  compare  the  relative  height  of  the  malleoli  above 
the  heel  on  the  two  sides,  since  a  lessened  distance  is  proof  of 
fracture  of  the  astragalus  or  os  calcis  or  both.  Thickening  at 
this  point  and  slight  lateral  displacement  of  the  foot  are  con- 
firmatory signs. 

In  fractures  of  this  class,  the  upper  articulating  surface  of 
the  astragalus  often  retains  its  normal  contour.  So  that  dorsal 
and  plantar  flexion  may  be  but  slightly  restricted  while  adduc- 
tive  and  abductive  movements  proper  to  the  subastragaloid 
joints  are  lost. 

Treatment.. — In  all  suspicious  cases  X-ray  pictures  should  be 
taken  and  if  fracture  and  displacement  are  present,  one  should 
under  anaesthesia  attempt  to  mould  the  foot  to  an  approximately 
normal  contour,  especially  at  the  arch.  This  is  important  if  the 
OS  calcis  is  fractured,  as  one  of  the  fragments  is  often  forced 
downward  into  the  tissues  of  the  sole.  A  plaster  bandage  is 
then  applied  after  consolidation  of  the  fracture.  Passive  move- 
ments should  be  persistently  eiuployed  particularly  in  adduc- 
tion. As  a  rule  an  arched  foot  plate  should  be  worn  during  the 
period  of  recovery.  In  certain  instances  operative  treatment 
is  indicated  to  remove  projecting  fragments  of  bone,  or  the 
entire  astragalus  if  the  joint  is  disorganized. 

Fracture  of  the  other  bones  of  the  tarsus  is  uncommon  and 
the  accident  is  of  comparatively  slight  importance. 


478 


ORTHOPEDIC  SUBGEBY. 
TENOSYNOVITIS. 


The  sheaths  of  the  tendons  about  the  ankle-joint,  if  involved 
in  a  sprain  of  the  ankle,  may  cause  persistent  interference  with 


Fig.  315. 


The  anterior  annular  ligament 
of  the  ankle  and  the  synovial 
membranes    of    the    tendons    be- 


FiG.  316. 


The  internal  annular  ligament  of  the  ankle  and 
the  artificially  distended  synovial  membranes  of  the 
tendons  vi^hich  it  confines.  (Testut,  from  Gerrish's 
Anatomy.) 

Fig.  317. 


The   external    annular   ligament    of   the   ankle   and 


neath     it     artificially     distended.  the   artificially   distended   synovial   membranes   of   the 


(Testut,     from     Gerrish's     Anat- 
omy.) 


tendons   which   it   confines.      (Testut,    from   Gerrish's 

Anatomi/.) 


DISEASES  AND  INJUEIES  OF  THE  ANKLE-JOINT.        479 

function;  or  strain  of  a  tendon  and  of  its  sheath  may  induce 
disability  if  the  ^oint  is  uninjured.  The  symptoms  of  acute 
tenosynovitis  are  discomfort  on  motion  of  the  affected  tendon, 
and  this  motion  may  be  accompanied  by  a  peculiar  creaking 
which  is  ajDparent  on  palpation  and  usually  there  is  slight  local 
swelling  and  sensitiveness  to  pressure  about  the  affected  part. 

At  the  ankle-joint  all  the  tendons  are  provided  with  sheaths; 
on  the  front  of  the  foot  are  three — the  sheath  of  the  tibialis 
anticus,  which  extends  from  a  point  about  two  inches  above  the 
extremity  of  the  malleolus  to  the  navicular  bone  (Fig.  315)  ; 
that  of  the  extensor  longus  hallucis,  from  the  annular  ligament 
to  the  head  of  the  first  metatarsal,  and  the  common  sheath  for 
the  extensor  communis  digitorum,  extending  from  a  point  about 
half  an  inch  above  the  malleoli  to  about  one  inch  below  the  annu- 
lar ligament.  Behind  the  internal  malleolus  are  the  common 
sheaths  of  the  tibialis  j^osticus  and  flexor  longus  digitorum,  be- 
ginning about  an  inch  above  the  extremity  of  the  malleolus  and 
extending  to  the  astragalo-navicular  junction  and  that  of  the 
flexor  longus  hallucis  of  about  the  same  extent  (Fig.  316).  Be- 
hind the  outer  malleolus  is  the  sheath  of  the  two  peronei,  be- 
ginning one  inch  above  the  malleolus,  dividing  into  two  portions 
for  the  two  tendons  and  ending  just  behind  the  tuberosity  of  the 
fifth  metatarsal  bone  (Fig.  317). 

Treatment. — Simple  traumatic  tenosynovitis  should  be  treated 
hj  rest  and  by  compression.  An  effective  treatment  is  strapping 
with  adhesive  plaster,  so  applied  as  to  prevent  the  movements  of 
the  foot  that  cause  discomfort.  In  more  painful  and  persistent 
cases  a  plaster  bandage  to  assure  absolute  rest  may  be  necessary. 
Cautery  applied  over  the  affected  part  is  of  service..  Chronic 
tenosynovitis  may  follow  injury  or  it  may  be  the  result  of 
gonorrhoea  or  other  infectious  disease.  In  chronic  cases  when 
the  palliative  treatment  is  ineffective,  thorough  removal  of  the 
affected  sheath  is  indicated.     (See  Achilobursitis.) 

Tuberculous  Tek^osyxovitis. — A  persistent  and  increasing 
swelling  of  a  tendon  sheath  always  suggests  tuberculous  disease. 
In  such  instances  the  sac  is  thickened  and  often  contains  the 
so-called  rice  bodies.  Prompt  and  complete  removal  of  the  dis- 
eased sheath  is  indicated,  and  by  this  means  a  permanent  cure 
may  be  attained  in  most  instances. 


480 


OBTHOPEDIC  SUBGEEY. 


SWELLING  ABOUT  THE  ANKLES. 

Occasionally  often  in  combination  with  weak  feet  there  are 
distinct  swellings  about  the  ankles.  The  most  common  is  m 
front  of  the  external  malleoli.  This  is  apparently  an  extrusion 
from  the  joint  made  up  of  synovial  and  fatty  tissue.  In  most 
instances  the  patients  are  fat  and  the  apparent  cause  is  over- 
weight. 

Fig.  318. 


Painful  swellings  about  the  ankles,   common  in  over-weighted  subjects. 

The  patients  usually  complain  of  weakness  and  discomfort. 
The  treatment  aside  from  reduction  of  weight,  and  support  for 
the  weakened  arch,  is  massage,  strapping  and  bandaging.  The 
operative  removal  of  the  swollen  tissue  is  indicated  in  obstinate 
cases. 


CHAPTER  XII. 

DISEASES    AND    INJUEIES    OE    THE    ARTICULATIONS    OF    THE 
UPPEE  EXTEEMITY. 

TUBERCULOUS  DISEASE  OF  THE   SHOULDER-JOINT. 

Disease  at  the  shoulder  is  very  uncommon  in  childhood.  In 
a  total  of  453  cases  of  tuberculous  disease  treated  at  the  Vander- 
bilt  clinic  210  were  cases  of  Pott's  disease.  In  6  of  the  remain- 
ing 243  cases  the  disease  was  of  the  shoulder-joint  (2.5  per 
cent. ) . 

In  1883  consecutive  cases  of  joint  disease — Pott's  disease 
being  excluded — ^treated  in  the  out-patient  department  of  the 
Hospital  for  Euptured  and  Crippled  in  a  period  of  five  years, 

Fig.  319. 


Section  of  the  shoulder-joint  at  the  age  of  eight  years.  (Schuchardt.)  Ossi- 
fication appears  in  the  epiphysis  of  the  head  of  the  humerus  at  the  end  of  the 
first  year  ;  a  second  point  appears  in  the  greater  tuberosity  during  the  second 
year.  These  unite  between  the  fourth  and  sixth  years.  Ossification  is  complete 
between  the  eighteenth  and  twentieth  years.  The  angle  formed  by  the  head  and 
shaft  is  from  130°-140°.  The  range  of  motion  at  the  joint  between  adduction 
and  abduction  is  about  90°  and  between  flexion  and  extension  (anteroposterior 
movement)   somewhat  less. 

the  shoulder-joint  was  involved  in  38  instances  (2  per  cent.). 
Of  1900  cases  of  joint  disease  treated  at  Billroth's  clinic,  the 
shoulder  was  involved  in  14,  or  less  than  1  per  cent.  At  the 
Boston  Children's  Hospital  but  17  cases  were  recorded  in  a 
total  of  7474  cases  of  tuberculous  disease  of  spine  and  joints, 
illustrating  its  infrequency  in  early  life.^ 

^  Sever,  Bost.  Med.  &  Surg.  Journal,  March  24,  1910. 
31  481 


482 


ORTHOPEDIC  SUEGEEY. 


Pathology. — The  disease  usually  "begins  in  the  head  of  the 
humerus.  In  32  observations  on  adults  recorded  by  Mondan 
and  Andry/  the  primary  disease  was  of  the  head  of  the  humerus 
in  23  cases,  of  the  humerus  and  scapula  in  4,  of  the  scapula 
alone  in  1,  and  in  3  instances  it  appeared  to  be  primarily 
synovial. 

In  the  majority  of  cases  abscess  forms  and  appears  near  the 
anterior  insertion  of  the  deltoid  muscle.  In  advanced  cases  the 
tissues  of  the  axilla  and  of  the  adjoining  thorax  may  be  infil- 
trated and  perforated  by  numerous  sinuses.  I^ot  infrequently 
the  disease  is  of  the  form  called  caries  sicca,  in  which  there  is 
no  swelling,  but  progressive  destruction  of  the  head  of  the 
humerus  by  granulation  tissue.  This  form  is  characterized  by 
extreme  muscular  atrophy  and  by  practical  anchylosis. 

Townsend^  made  a  detailed  report  on  21  cases  treated  at 
the  Hospital  for  Ruptured  and  Crippled  during  the  years 
1889  to  1893.  Ten  of  these  were  less  than  ten  years  of  age;  7 
Avere  between  ten  and  twenty,  and  4  were  more  than  twenty. 
The  youngest  patient  was  three  and  a  half  and  the  age  of  the 
oldest  was  thirty-five  years.  In  5  cases  the  disease  was  secon- 
dary to  disease  of  other  parts ;  in  1  case  to  Pott's  disease ;  in  2 
to  hip  disease,  and  in  2  to  disease  of  the  knee-joint. 

Age  at  Incipiency  of  Disease  at  the  Shoulder- joint  in  Sixty-two 
Consecutive  Cases  Treated  at  the  Hospital  for  Euptured  and 
Crippled. 


1  year  or  less   

2  years   old 

3  ''        

1 

6 

1 

13  years  old 

15           ''        

18           " . 

3 

2 

3 

4            "        

3 

19           "        

5 

5           "        

3 

20           "        

4 

6           "        

1 

23           "        

1 

7           "        

3 

4 

26           "        

2 

8           "        

27           "        

1 

9           "        

6 

34           ' '        

1 

10           "        

1 

48           "        

1 

11           "        

5 

56           "        

1 

12           "        

4 

Total 

62 

Males,  38;   females,  24;   right,  35;   left,  27. 

Symptoms.- — The  history  of  the  ease  will  indicate  the  persis- 
tent and  progressive  character  of  the  disability,  but  the  symp- 
toms characteristic  of  tuberculous  disease  are  far  less  marked  at 
the  shoulder  than  at  other  joints.  This  is  explained  by  the  fact 
that  the  upper  extremity  is  not  subjected  to  weight  bearing  and 
because  the  mobility  of  the  scapula  upon  the  thorax  lessens  the 

'Kevue  de  Chir.,  1892. 

"  Transactions  American  Orthopedic  Association,  vol.  vii. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITYAS^ 


injury  caused  bj  unguarded  movements  of  the  arm.  This 
movement  at  the  shoulder  masks  the  interference  with  the  func- 
tion of  the  joint,  and  the  strain  caused  bj  overuse  may  be 
lessened  by  the  unconscious  restraint  that  the  patient  can  ex- 

FiG.  320. 


Tuberculous  disease   of  the  shoulder-joint. 

ercise  upon  motion  at  this  joint.  In  fact,  even  when  anchylosis 
is  present  the  patient  may  think  that  motion  is  but  moderately 
restricted. 

The  symptoms  of  the  disease  may  be  classified  as  pain,  sensi- 
tiveness, restfiction  of  motion,  atrophy. 

There  is  usually  a  dull  ache  about  the  joint,  with  occasional 
neuralgic  pain  referred  to  the  elbow  and  arm.  The  discomfort 
is  increased  by  movements  that  pass  beyond  the  limits  allowed 
by  the  mobility  of  the  scapula,  especially  on  attempting  to  rotate' 
the  humerus,  as  in  clothing  one's  self  or  brushing  the  hair.  The 
joint  is  sensitive  to  pressure;  thus  the  patient  finds  that  he  can- 
not lie  on  the  affected  side  at  night. 


484  OBTHOPEDIC  SUEGEBY. 

On  examination  the  limitation  of  motion  caused  by  muscular 
spasm  will  be  evident  if  the  scapula  is  fixed. 

Pressure  about  the  head  of  the  humerus  usually  causes  pain, 
and  in  many  instances  local  heat  and  swelling  are  present.  The 
atrophy  of  the  shoulder  muscles  is  often  extreme  and  that  of  the 
other  muscles  of  the  limb  is  well  marked. 

As  has  been  stated,  abscess  is  a  common  accompaniment  of 
the  disease,  and  in  such  cases  the  tissues  about  the  joint  are 
swollen  and  infiltrated.  In  other  instances  there  is  progressive 
destruction  of  the  head  of  the  humerus  without  abscess  forma- 
tion (caries  sicca).  In  cases  of  this  type  the  flattening  of  the 
shoulder  may  be  so  extreme  as  to  be  mistaken  for  subcoracoid 
dislocation. 

Treatment. — The  treatment  of  the  disease  here  as  elsewhere 
is  rest.  To  assure  absolute  functional  rest  the  wrist  should  be 
attached  to  the  neck  by  a  sling,  the  elbow  being  flexed  to  an 
acute  angle;  the  arm  is  then  fixed  to  the  thorax  by  a  bandage. 
Local  rest  and  compression  may  be  still  further  assured  by  strips 
of  adhesive  plaster  applied  over  the  shoulder  and  extending  to 
the  back  and  chest ;  or  a  shoulder-cajD  of  leather  or  plaster  may 
be  employed.  This  method  of  fixing  the  bare  arm  to  the  chest  is 
the  only  one  that  assures  continuous  rest,  as  changes  of  the 
•clothing  necessitate  movement  of  the  joint.  During  the  acute 
phases  of  the  disease  the  arm  may  be  supported  in  the  attitude 
of  abduction  by  means  of  a  triangular  s]3lint  or  by  a  thick  pad 
of  cotton  in  the  axilla.  Direct  traction  is  not  often  employed, 
as  support  of  the  pendent  limb  is  usually  preferred  by  the 
patient. 

If  the  focus  of  disease  seems  to  be  localized,  an  exploratory 
operation  for  its  early  removal  may  be  indicated.  Arthrectomy 
in  younger  subjects  may  be  advisable  when  suppuration  is 
persistent  or  when  for  other  reasons  it  may  seem  best  to  attempt 
to  remove  the  diseased  area.  Excision  of  the  joint  may  be  ad- 
visable for  the  purpose  o:£  restoring  motion  in  adolescent  or 
adult  cases. 

Prognosis.- — The  duration  of  the  disease  appears  to  be  from 
two  to  five  years.  The  death-rate  is  higher  than  in  disease  of 
the  joints  of  the  lower  extremity,  because  a  larger  proportion  of 
the  patients  are  adults,  and  in  this  class  tuberculosis  of  the 
lungs  is  not  an  infrequent  complication. 

It  is  impossible  to  speak  positively  of  the  results  of  the  con- 
servative treatment  of  disease  of  the  shoulder.     The  disease  is 


DISEASES  OF  ASTICULATIONS  OF  UPPEE  EXTEEMITY. 4S5 

uncommon,  and  protection  is  almost  never  applied  in  the  in- 
cipient stage,  nor  efficiently  and  persistently  employed  to  the 
end.  The  ordinary  result  is,  therefore,  anchylosis,  usually  of 
the  fibrous  rather  than  of  the  bony  variety. 

If  the  disease  appears  in  early  life  the  grov^^th  of  the  limb  may 
be  seriously  interfered  with;  an  inch  or  more  of  shortening 
from  this  cause  is  not  uncommon. 

TUBERCULOUS    DISEASE    OF    THE    ELBOW-JOINT. 

Tuberculous  disease  of  the  elbow-joint  is  the  fourth  in  order 
of  frequency,  preceding  the  shoulder  and  the  wrist.  Of  1883 
consecutive  cases  of  joint  disease  treated  at  the  Hospital  for 
Ruptured  and  Crippled  56  were  of  the  elbow. 

Pathology. — The  primary  disease  is  in  most  instances  osteal 
as  in  92.8  per  cent,  of  the  cases  investigated  by  Scheimpflug,  44 
in  number.^  The  original  focus  of  infection  is  somewhat  more 
often  of  the  ulna  than  of  the  humerus.  Of  the  ulna  the  ole- 
cranon process,  and  of  the  humerus  the  external  condyle,  appear 
to  be  the  points  of  election.  Disease  of  the  head  of  the  radius 
is  comparatively  infrequent. 

Occurrence. — In  119  cases  reported  by  Oilier  the  olecranon 
was  involved  in  Y3,  the  humerus  in  33,  and  the  radius  in  12 
instances.^  And  in  the  cases  investigated  by  Kummer,^  and 
Middledorpt,"^  the  ulna  was  more  often  the  seat  of  the  primary 
disease  than  was  the  humerus,  but  in  81  cases  treated  in 
Koenig's  clinic  the  j)rimary  disease  was  of  the  humerus  in  43,  of 
the  olecranon  in  36,  and  of  the  radius  in  2  instances.^ 

Age  at  Incipiency  of  Disease  at  the  Elbow-joint  in  Fifty-nine  Con- 
secutive Cases  Treated  at  the  Hospital  for  Ruptured  and  Crippled. 

13  years  old 3 

"  2 

" 1 

"  1 

"  1 

"  1 

"  1 


1  year  or  less 

2 
5 

13 

3     "   

8 

15 

4     "        

0 

17 

5     "        

5 

19 

6     "    

4 

21 

7     "        

8 

23 

8     "        

1 

25 

9     "        

2 

29 

10     "        

5 

11     "        

1 

1 

Total 59 


Males,  28;  females,  31;  right,  27;  left,  32. 

^  Festschrift  f iir  Billroth,  1892. 

^  Karewski,  Chir.  Krank.  des  Kindersalters,  p.  268. 

^  Deutsche  Zeits.  f .  Chir.,  Bd.  xxvii. 

*  Archiv  f .  klin.  Chir.,  Bd.  xxxiii. 

°  Koenig,  Lehrbuch  Spec.  Chir.,  Berlin,  1900.  Sever  reports  50  cases  in 
a  total  of  7,474  cases  of  spine  and  joint  tuberculosis  treated  at  the  Boston 
Children's  Hospital.     Bost.  Med.  and  Surg.  J.,  May  19,  1910. 


486 


OBTHOPEDIC  SUEGEBY. 


Symptoms. — The  symptoms  are  those  of  a  chronic,  persistent, 
destructive  disease — jxiin^  local  sensitiveness  and  swelling,  stiff- 
ness, deformity,  atrophy. 

The  pain  is  usually  localized  at  the  elbow.  It  is  increased  by 
sudden  movements,  and  as  the  bones  are  so  superficial  there  is 
usually  local  sensitiveness  to  pressure,  most  marked  over  the  seat 
of  the  disease.  In  the  early  stage  the  swelling  is  slight,  and  it 
is  of  the  peculiar  elastic  character  due  to  thickening  of  the 

Fig.  321. 


Tuberculous  disease  of  the  elbow-joint. 


tissue  rather  than  to  effusion  within  the  capsule,  but  as  the 
disease  progresses  the  joint  assumes  the  peculiar  spindle  shape 
characteristic  of  white  swelling.  The  degree  of  elevation  of  the 
local  temperature  depends  upon  the  activity  of  the  disease.  The 
most  important  physical  sign  is  the  restriction  of  motion  due  to 
the  characteristic  muscular  spasm  which  becomes  evident  when 
the  limit  of  painless  motion  is  passed.  The  limitation  of  ex- 
tension and  flexion  gradually  increases,  and  finally  the  limb  be- 
comes fixed  in  an  attitude  midwav  between  flexion  and  exten- 


DISEASES  OF  ARTICULATIONS  OF  UPFEB  EXTEEMITTAS7 

sion,  with  the  forearm  in  an  attitude  between  pronation  and 
supination.  This  is  the  characteristic  deformity  of  the  disease. 
Atrophy  of  the  muscles  of  the  arm  and  forearm  is  present, 
corresponding  to  the  intensity  and  duration  of  the  disease  and 
to  the  functional  disability  of  the  joint. 

Fig.  322. 


Tuberculous  disease  of  the  elbow-joint ;  the  stage  of  recovery. 


Treatment. — The  treatment  here  as  elsewhere  consists  essen- 
tially in  placing  the  joint  at  rest  in  the  attitude  at  which  anchy- 
losis or  limitation  of  motion  will  least  inconvenience  the  patient, 
and  at  the  elbow-joint  this  is  practically  at  right  angular  flexion 
(Fig.  322). 

In  the  treatment  of  young  children  the  wrist  may  be  attached 
closely  to  the  neck  by  means  of  a  sling,  in  an  attitude  of  acute 
flexion  at  the  elbow  (the  Thomas  method)  within  the  clothing. 
Or  a  light  plaster  splint  may  be  used  to  fix  the  joint,  the  wrist 
being  supported  by  a  sling.  This  enables  the  patient  to  dress 
himself  without  moving  the  joint  and  at  the  same  time  protects 
it  from  injury.  Other  forms  of  splints  may  be  employed,  but 
the  plaster  support  answers  every  purpose.    It  should,  of  course, 


488  OBTHOPEDIC  SUBGEEY. 

extend  from  the  axilla  to  the  wrist,  and  in  sensitive  cases  it  may 
include  the  hand  also.  The  Bier  treatment  may  be  easily  ap- 
plied and  its  effects  should  be  tested  in  all  cases. 

Reduction  of  Deformity. — In  many  instances  the  arm  is  fixed 
in  the  semi-extended  attitude  when  the  patient  is  brought  for 
treatment.  A  simple  and  effective  means  of  reducing  deformity 
in  childhood  is  that  suggested  by  Thomas.  When  it  is  im- 
possible to  bring  the  wrist  to  the  neck,  one  bends  the  neck  toward 
the  wrist  and  attaches  the  two  by  a  bandage  that  the  patient  is 
unable  to  remove.  From  this  uncomfortable  attitude  the  patient 
can  free  himself  only  by  drawing  the  forearm  toward  the 
neck  and  thus  reducing  the  deformity.  At  the  next  visit  the 
same  procedure  is  repeated,  until  finally  the  elbow  is  flexed  to 
the  required  degree.  A  permanent  sling  may  be  constructed  of 
a  leather  wrist-band  and  a  tube  of  leather  to  pass  about  the  neck, 
through  which  the  bandage  may  be  drawn;  thus  the  pressure 
on  the  wrist  and  neck  may  be  lessened.  In  the  very  resistant 
cases  reduction  of  deformity  under  anaesthesia  may  be  required 
but  this  is  not  often  necessary. 

Operative. — In  some  instances  it  is  possible  to  remove  small 
foci  of  disease  from  the  humerus,  or  from  the  adjoining  bones, 
before  the  joint  is  involved.  The  position  of  the  disease  may  be 
indicated  by  sensitiveness  or  swelling,  and  in  older  subjects  a 
Roentgen  picture  may  demonstrate  its  position  accurately. 

Excision  of  the  Elbow. — Excision  is  often  advisable  in  adoles- 
cent or  adult  life,  because  by  this  procedure  the  disease  may  be 
removed  in  most  instances,  and  because  motion  may  be  assured. 

Oschman  has  recently  investigated  the  final  results  of  the 
operation  performed  on  this  class  at  Kocher's^  clinic  at  Berne, 
1872-1897.  In  40  of  45  cases  the  operation  was  performed  for 
tuberculous  disease.  There  were  no  deaths  referable  to  the 
operation.  Of  the  entire  number  of  cases  15  were  dead,  but  11 
of  these  survived  the  operation  for  from  five  to  twenty  years. 
Eight  of  the  deaths  were  due  to  tuberculosis,  2  to  other  causes, 
and  in  5  the  cause  of  death  was  unknown.  In  96  per  cent,  of 
the  cases  the  local  disease  was  cured.  In  68  per  cent,  of  the 
cases  the  patients  were  able  to  use  the  limb  at  hard  labor,  and 
in  the  others  it  was  efficient  for  light  work.  In  6  cases  there 
was  subluxation  or  luxation;  in  5  the  joint  was  not  firm.  In 
59  per  cent,  the  motions  were  practically  normal.  In  11  per 
cent,  the  joint  was  anchylosed. 

^Arehiv  f.  klin.  Chir.,  Bd.  Ix.,  H.  2. 


DISEASES  OF  ABTICULATIONS  OF  UPPEB  EXTBEMITYASd 


Prognosis. — If  the  case  is  treated  at  an  early  stage  the  prog- 
nosis in  childhood  is  good.  The  duration  of  treatment  may  be 
estimated  at  two  years  or  more,  and  a  fair  range  of  motion  will 
be  preserved  in  half  the  cases.  Anchylosis  in  the  right-angled 
position  does  not,  however,  seriously  inconvenience  the  patient, 
provided  the  cure  is  absolute.  The  loss  of  growth  is  usually  less 
than  when  the  upper  epiphysis  of  the  humerus  has  been  de- 
stroyed, the  final  disproportion  depending,  of  course,  upon  the 
age  of  the  patient   and  upon  the  degree  of  function  that  is 

preserved.^ 

Fig.  323. 


Tuberculous  disease  of  the  wrist  and  knee-joints,  showing  the  characteristic  de- 
formities in  neglected  cases  of  a  severe  type. 

TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT. 

Disease  of  the  wrist-]  oint  is  very  uncommon  in  childhood. 
In  a  total  of  3105  cases  of  tuberculous  disease  treated  in  the 
out-patient  department  of  the  Hospital  for  Kuptured  and  Crip- 
pled during  a  period  of  five  years,  98  were  of  the  upper  ex- 
tremity, and  in  but  4  of  these  was  the  wrist-joint  involved.  Of 
43  cases  in  which  the  joint  was  resected  by  Oilier,  the  youngest 
patient  was  thirteen  years  of  age. 

Of  990  cases  of  disease  of  the  joints  in  childhood,  reported  by 

Karewski,  the  wrist  was  involved  in  31.^ 

iln  38  final  results  of  non-operative  treatment .  reported  by  Sever  good 
motion  was  retained  in  12.     In  16  anchylosis  was  present.     (Locus  cit.) 
^  Chir.  Krank.  des  Kindersalters,  Berlin,  1894. 


490  OBTHOPEDIC  SUFGEEY. 

Disease  of  the  wrist  in  older  subjects  is  less  infrequent, 
althoiigli  at  all  ages  it  is  rare  as  compared  with  disease  in  other 
joints.  Tuberculous  disease  of  the  metacarpus  and  phalanges 
(spina  ventosa)  is,  however,  far  more  common. 

Age  at  Ixcipiexcy  of  Disease  at  the  Weist-joixt  ix  Eighteen  CoxsEcr- 
TivE  Cases  Treated  at  the  Hospital  for  Euptured  axd  Crippled. 

2  years  old 1        .9  rears  old 2 

6 


9 
12 
14 
16 
17 


1 

20 
25 
26 
27   ■ 

I  i 

9 

1 

I  i 

9 

9, 

i  i 

2 

1 

1 1 

1 

2 

1 

Total 

18 

Males,  11;   females,  7;   right,  12;  left,  6. 


Symptoms.- — The  symptoms  of  tuberculous  disease  of  the  wrist 
are,  as  in  other  situations,  pairij,  local  siveTling,  and  sensitiveness, 
limitation  of  motion,  caused  bv  muscular  spasm,  and  atrophy. 
In  advanced  cases  the  hand  is  usually  flexed  somewhat  upon 
the  arm. 

Treatment — The  treatment  of  this,  as  of  other  joints,  is  func- 
tional rest,  with  support  in  the  attitude  in  which  anchylosis  or 
limitation  of  motion  will  cause  the  least  inconvenience.  A  light 
plaster  bandage  extending  from  the  elbow  to  the  tips  of  the 
fingers,  applied  over  a  flannel  bandage  drawn-  as  tight  as  the 
comfort  of  the  patient  will  permit,  is  a  satisfactory  support ;  or 
a  leather  splint  or  other  form  of  appliance  may  be  used.  The 
hand  should  l)e  supported  in  an  attitude  of  moderate  dorsal 
flexion,  which  will  permit  the  flexor  muscles  to  close  the  fingers 
easily  if  the  wrist  becomes  fixed  by  the  disease.  If  flexion  de- 
formity is  present  it  should  be  corrected  slightly  at  each  applica- 
tion of  the  bandage,  until  the  desired  attitude  is  attained  (Fig. 
325).  The  flannel  bandage  exercises  a  certain  amount  of  com- 
pression upon  the  wrist,  which  seems  to  be  of  benefit,  and  in 
certain  instances  this  compression  and  fixation  may  be  still 
further  increased  by  the  application  of  adhesive  plaster.  Bier's 
treatment  by  passive  congestion  may  be  applied,  and  according 
to  reports  it  is  especially  efiicacious  in  this  situation.  When  the 
disease  of  the  joint  is  quiescent,  or  in  the  stage  of  recovery,  the 
bandage  or  splint  may  be  shortened  to  permit  the  use  of  the 
fingers. 

Prognosis.- — The  prognosis  as  regards  function  in  cases  treated 
promptly  in  childhood  should  be  good.  In  the  adult  cases  wrist- 
joint  disease  seems  to  be  very  often  accompanied  by  disease  of 


DISEASES  OF  AETICULATIONS  OF  VFFEFi  EXTREMITY A^l 

the  kiDgs ;  thus  the  progiiosis  as  to  life  is  bad.  In  this  class  of 
cases  early  excision  is  usually  recommeixled,  with  amputation 
as  a  final  resort. 

SPINA  VENTOSA. 

Central  disease  of  the  long  bones  of  the  foot  and  hand  is  the 
most  common  form  of  diaphyseal  tuberculosis.     While  the  cor- 

FiG.  324. 


Tuberculous  disease  of  the  right  wrist-joint,  showing  the  swelling  and  the  limi- 
tation of  motion. 


Fig.  325. 


Treatment    of    tuberculosis    of    the    wrist-joint    by    plaster-of-Paris,    showing   the 

proper  attitude. 


492 


OETHOPEDIC  SUHGEEY. 


tical  substance  is  destroyed  from  within  it  is  often  replaced  in 
part  IjT  a  formation  of  periosteal  bone  from  without,  which  in 


Fig.  326. 


Tuberculous  disease  of  the  carpus. 
Fig.  327. 


Tuberculous  disease  of  the  left  wrist-joint.  The  irregularity  and  the  di- 
minished size  of  the  carpal  bones  indicate  the  extent  of  the  destructive  process. 
The  patient,  the  mother  of  the  child  (Figs.  10  and  11)  with  Potfs  disease,  died 
within  a  year,  of  tuberculosis  of  the  lungs. 


turn  may  be  destroyed  by  the  advancing  disease.     In  the  earlv 
cases  the  affected  bone  is  enlarged,  sjDindle-shaped,  and  is  some- 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITTA93 

what  sensitive  to  pressure.  At  this  stage  repair  may  take  place 
with  but  little  ultimate  change  from  the  normal,  but  in  many 
instances  the  bone  is  perforated  and  in  part  destroyed,  the  neigh- 
boring joint  is  involved,  and  the  finger  becomes  stunted  and 
distorted. 

In  159  cases  tabulated  by  Karewski/  the  metacarpal  bones 
were  diseased  in  65  instances;  the  phalanges  in  57;  the  meta- 
tarsal bones  in  29 ;  the  phalanges  of  the  toes  in  8.  In  a  number 
of  instances  several  of  the  bones  and  larger  joints  were  involved 
also  (159  cases  in  135  patients). 

The  disease  is  more  common  in  the  early  years  of  life,  84  of 
the  135  patients  being  four  years  of  age  or  less,  38  of  these  being 
less  than  two. 

Spina  ventosa  of  the  phalanges  may  be  treated  by  rest  and 
compression,  and  both  splinting  and  compression  may  be  assured 
by  adhesive  plaster  strapping.  If  the  joint  is  involved  amputa- 
tion of  the  finger  may  be  indicated,  because  of  the  distortion  and 
loss  of  growth  that  may  be  expected.  Tuberculous  disease, 
limited  to  a  single  bone  of  the  carpus  or  metacarpus,  may  be 
treated  by  operative  removal  of  the  disease. 

PERIARTHRITIS  OF  THE  SHOULDER. 

Under  the  title  of  scapulohumeral  periarthritis,  Duplay^  in 
1872  described  a  painful  affection  of  the  shoulder  induced  by 
injury,  dependent  upon  an  inflammation  of  the  bursa  lying 
between  the  deltoid  and  supraspinatus  and  infraspinatus 
muscles  and  the  coracoacromial  ligament.  But  under  this  title 
are  now  included  a  number  of  affections  that  cause  similar 
symptoms  in  which  it  would  appear  that  the  interior  of  the  joint 
is  not  involved. 

Sjnnptoms.- — In  a  typical  case  of  so-called  periarthritis  the 
patient  complains  of  a  dull  pain  about  the  joint  and  sensitive- 
ness to  pressure  just  below  the  acromion  process  or  over  the 
bicipital  groove  and  occasionally  a  swelling  is  evident  on  the 
anterior  aspect  of  the  joint.  The  pain  is  increased  by  motion, 
particularly  by  abduction  or  by  rotation  of  the  arm.  In  mild 
cases  only  extensive  motion  causes  pain,  but  in  most  instances 
there  is  a  constant  sensation  of  discomfort  which  is  increased 
to  acute  pain  by  sudden  movements  or  jars.  The  part  becomes 
sensitive  to  pressure,  so  that  the  patient  avoids  lying  on  the 

^  Chir.  Krank.  des  Kindersalters,  Berlin,  1894. 
-Archiv.  generale  de  med.,  Paris,  1872. 


494 


OETHOPEDIC  SUEGERY. 


shoulder  at  night.  In  certain  instances  the  pain  may  radiate 
down  the  arm.  and  there  may  be  weakness  and  numbness  of  the 
fingers.      Gradually  the   passive  movements   of  the  joint  are 


Fig.  328. 


^?auc 


C/f_ 


mcoarromial  ligament. 
Acromion  process. 
Subdeltoid  burse 
■^  injected  with 


Tlif  sulKleltuid  bursa.       (Baer.) 


diminished  in  range,  and  atrophy  of  the  shoulder  muscles  ap- 
pears. 

These  symptoms  usually  pass  as  rheumatism,  but  there  is  no 
fever,  no  involvement  of  other  joints,  no  swelling,  and,  as  a  rule^ 
no  general  sensitiveness  to  pressure,  as  is  usual  when  the  syno- 
vial membrane  of  the  joint  is  affected.     In  certain  instances  the 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTBEMITYAd5 

symptoms  follow  injury,  or  exposure  to  cold,  or  they  appear 
without  apparent  cause.  In  typical  cases  the  symptoms  are 
due  to  inflammation  of  the  subdeltoid  bursa,  as  originally  de- 
scribed by  Duplay.  This  bursa  lies  beneath  the  deltoid  muscle 
separating  it  from  the  joint.  According  to  Baer  it  is  about  the 
size  ola  silver  half  dollar  (Fig.  329).  It  sends  a  prolongation 
beneath  the  acromion  process  and  the  coracoacromion  ligament. 
If  the  bursa  is  enlarged  it  presents  a  mechanical  obstacle  to  ab- 
duction and  in  acute  cases  one  that  is  sensitive  to  pressure.  In 
other  cases  of  a  less  marked  type  tenosynovitis  of  the  biceps  ten- 
don may  be  present.  This  is  suggested  by  local  sensitiveness  at 
the  bicipital  groove,  and  by  the  creaking  sensation  at  this  point 
when  the  muscle  is  in  use.  It  is  probable  also  that  in  some  cases 
the  nerves  in  the  neighborhood  of  the  joint  may  be  secondarily 
implicated  in  an  inflammation  of  bursse,  or  directly  injured  by 
the  original  traumatism,  if  such  preceded  the  symptoms.  Thus 
neuritis  may  add  to  the  discomfort  and  prolong  the  disability. 

Treatment. — During  the  acute  and  painful  stage  the  part 
should  be  kept  at  rest.  Cautery  may  be  applied  and  the  joint 
should  be  enclosed  in  adhesive  plaster  strapping,  and  if  the 
weight  of  the  limb  causes  discomfort  it  should  be  supported.  In 
certain  instances  tension  on  the  sensitive  part  may  be  relaxed 
by  supporting  the  arm  in  an  attitude  of  slight  abduction.  When 
the  acute  symptoms  have  subsided  passive  movements,  massage, 
and  static  electricity  are  of  service.  Voluntary  exercises  should 
be  employed  when  they  no  longer  aggravate  the  symptoms.  In 
the  cases  of  long  standing  in  which  motion  is  very  much  re- 
stricted, apparently  by  adhesions  without  the  joint,  passive 
movements  under  anaesthesia  to  the  extremes  of  the  normal 
range  are  usually  of  benefit.  In  such  cases  it  may  be  well  to 
support  the  limb  for  a  time  in  the  abducted  attitude  to  prevent 
the  formation  of  the  adhesions.  Afterward  passive  motion, 
massage  and  exercise  must  be  employed  to  prevent  the  return 
of  the  restriction.  If  these  cases  are  treated  carefully  in  the 
early  stage,  recovery  is  usually  rapid,  but  if  neglected  the 
symptoms  may  persist  indefinitely.-^ 

Operative. — In  cases  in  which  it  is  evident  that  the  symptoms 
are  caused  by  a  congested  and  thickened  bursa  it  may  be  re- 
moved. An  incision  about  two  inches  in  length  is  made  through 
the  anterior  fibres  of  the  deltoid  muscle  and  the  entire  sac  is 

^  Cadman,  Bost.  Med.  &  Surg.  J.,  May  31,  1906.  Baer,  Johns  Hop.  Hosp. 
Bull.,  No.  195. 


496  OBTHOPEDIC  SUPiGERY. 

dissected  from  the  neighboring  tissues.     By  this  treatment  the 
period  of  stiifnes*  and  discomfort  is  materially  shortened. 

CHRONIC   BURSITIS. 

Chronic  bursitis  at  the  shoulder-joint  is  comparatively  infre- 
quent. The  bursse  most  often  involved  are  the  coracoid,  the 
subscapular,  and  the  deltoid.  Of  these  the  last  is  the  most  often 
affected.  Sixteen  cases  have  been  reported  by  Blauvelt/  and 
three  others  by  Ehrhardt.^  The  enlarged  bursa  forms  a  fluc- 
tuating sv^elling  most  noticeable  on  the  anterior  and  outer  aspect 
of  the  shoulder,  the  symptoms  being  discomfort,  weakness,  and 
limitation  of  motion  of  the  arm.  The  disease  is  usually  tuber- 
culous in  character,  and  it  should  be  treated  by  complete  re- 
moval of  the  sac  if  possible. 

SPRAIN  OF   THE  WRIST. 

This  is  a  very  common  accident.  The  most  effective  treat- 
ment is  the  adhesive  plaster  strapping  applied  about  the  meta- 
carpus, wrist,  and  lower  half  of  the  forearm.  If  the  pain  on 
motion  is  severe  sufficient  plaster  is  applied  to  splint  the  part 
and  to  limit  movement  to  the  point  of  comfort.  If  the  injury  is 
of  a  slighter  grade  the  compression  and  support  of  a  single  layer 
of  plaster  is  usually  sufficient.  This  dressing  prevents  strain, 
and  yet  it  permits  a  certain  degree  of  functional  use,  which  is  the 
most  effective  means  of  restoring  a  joint  to  its  normal  condition 
by  hastening  the  absorption  of  the  effused  material  within  and 
without  the  injured  part. 

Chronic  Sprain. — Persistent  weakness  and  stiffness  may  fol- 
low treatment  of  a  sprain  by  splints  or  when  for  any  reason 
disuse  of  function  has  been  long  continued.  In  many  instances, 
however,  the  sprain  was  in  reality  a  fracture  or  displacement  of 
the  carpus.  All  chronic  sprains,  therefore,  should  be  examined 
by  means  of  the  X-ray  in  order  that  the  presence  or  absence  of 
more  extensive  injury  may  be  determined. 

The  treatment  is  similar  to  that  of  the  acute  sprain :  protec- 
tion from  injury,  and  functional  use  to  the  extent  of  which  the 
part  is  capable.  With  this,  passive  congestion,  massage,  hot  air, 
and  electricity  or  other  form  of  local  stimulation  may  be  em- 
ployed with  advantage.     The  same  treatment  is  indicated  when 

^  Beitrage  zur  klin.   Chir.,  Bd.  xxii. 
=  Archiv.  f.  klin.  Chir.,  Bd.  Ix. 


DISEASES  OF  ABTICULATIONS  OF  UPPER  EXTREMITY.  497 

the  joint  is  stiff  and  painful  as  the  result  of  rheumatism  or  other 
inflammation,  provided  the  stage  of  recovery  has  been  reached. 

TENOSYNOVITIS. 

Acute. — Tenosynovitis  more  especially  of  the  flexor  tendons 
is  common  at  the  wrist-joint.  It  is  usually  induced  by  strain  or 
overuse  of  a  muscle  or  muscular  group. 

Movements  of  the  muscles  that  are  involved  cause  discomfort, 
and  there  is  usually  local  sensitiveness  and  a  creaking  sensation 
on  palpation  over  the  affected  tendon  sheath.  The  same  symp- 
toms with  more  sensitiveness  to  direct  pressure  may  be  caused 
by  inflammation  of  the  peritendinous  tissues.  The  adhesive 
plaster  strapping,  so  applied  as  to  exert  compression  and  to  pre- 
vent the  motion  that  causes  discomfort,  is  the  most  effective 
treatment. 

Chronic. — Chronic  tenosynovitis,  causing  progressive  enlarge- 
ment of  a  tendon  sheath,  with  accompanying  symptoms  of  weak- 
ness and  discomfort,  is  usually  tuberculous  in  character.  In 
such  cases  the  diseased  part  should  be  promptly  removed.  If 
the  disease  is  of  long  standing,  extending  into  the  palm  of  the 
hand  it  may  be  advisable  to  simply  evacuate  the  contents,  in- 
cluding the  rice  bodies,  through  an  incision.  An  astringent 
solution  may  be  injected,  and  after  its  removal  the  incision  may 
be  closed.  Pressure  is  then  applied,  with  the  aim  of  securing 
partial  adhesions  of  the  apposeel  surfaces. 


32 


CHAPTEE  XIII. 
DEFORMITIES  OF  THE  UPPER  EXTREMITY. 

CONaENITAL    DISLOCATION    OF    THE    SHOULDER. 

This  may  occur  in  tT\'o  forms,  one  in  which  there  is  actual 
misplacement  before  birth,  and  the  other  in  which  a  dislocation 
is  caused  by  violence  at  birth.  In  either  case  the  displacement 
is  almost  always  backward  upon-  the  dorsum  of  the  scapula  (sub- 
spinous). Thus  the  arm  is  abducted  and 'rotated  inward,  and 
the  head  of  the  displaced  bone  may  be  felt  in  its  abnormal  posi- 
tion. Cases, of  congenital  displacement  in  other  directions  are 
recorded,  but  these  are  so  unusual  as  to  be  of  little  practical 
importance.-^ 

True  primary  displacements  of  either  variety  are  compar- 
atively uncommon,  many  of  the  reported  cases  being  secondary 
to  the  habitual  malposition  induced  by  obstetrical  paralysis  (Fig. 
329).  According  to  Porter,^  twenty-nine  cases  are  recorded  in 
literature,  in  at  least  half  of  which  the  diagnosis  is  doubtful. 
It  is,  of  course  apparent  that  both  displacement  and  paralysis 
may  be  coincident  and  caused  by  injury  at  birth. 

OBSTETRICAL  PARALYSIS. 

Partial  or  complete  paralysis  of  the  muscles  of  the  arm  may 
be  a  result  of  difficult  or  protracted  labor.  It  may  be  induced 
by  direct  pressure  on  the  brachial  plexus,  but  most  often  it  is 
caused  by  traction  on  the  body  or  the  head,  or  by  violent  twists 
of  the  neck  during  delivery.  In  rare  instances  the  paralysis 
may  be  bilateral.  In  some  cases  the  nerve  roots  may  be  torn 
apart,  in  others  the  injury  may  be  principally  to  the  sheath 
causing  hemorrhage,  and  in  the  process  of  repair  scar  tissue  forms 
which  presses  upon  the  nerve  elements.  The  muscles  most  often 
paralyzed  are  those  supplied  principally  by  the  fifth  and  sixth 
cervical  roots  of  the  plexus — the  deltoid,  the  biceps,  and  the 
supinators  of  the  forearm.  Thus  in  most  instances  the  arm 
hangs  in  an  attitude  of  slight  abduction  and  exaggerated  prona- 
tion (Fig.  330).    If  the  attitude  is  allowed  to  persist,  the  head 

^  Scudder,  American  Journal  of  the  Medical  Sciences.  February,  1898. 
-  Transactions  American  Orthopedic  Association,  1900,  vol.  xiii. 

498 


DEFOBMITIES    OF    TEE    UPFEE    EXTBEMITY.  499 

of  the  humerus,  rotated  backward  beneatii  the  atrophied  deltoid 
muscle  and  finally  fixed  in  the  abnormal  attitude  by  accommo- 
dative changes  in  the  capsule  and  surrounding  parts,  simulates 
very  closely  in  later  years  the  true  congenital  dislocation  at  the 
shoulder  (Fig.  331). 

Fir,.  329. 


Congenital   dislocation  of  tlie  left  humerus,  illustrating  the  characteristic    ' 

attitude. 

Whether  cases  reported  as  congenital  displacement  of  the 
humerus  are  secondary  to  paralysis  or  not,  it  is  evident  that  all 
cases  of  obstetrical  paralysis  should  be  carefully  examined  with 
regard  to  a  complicating  dislocation,  and  that  the  secondary 
deformity  induced  by  paralysis  should  be  prevented. 

Treatment. — During  the  first  month  after  birth  the  shoulder 
of  the  paralyzed  arm  is  often  somewhat  swollen,  and  motion 
may  cause  pain.  In  such  cases  rest  is  indicated.  The  arm  should 
be  placed  against  the  side,  and  the  hand,  with  the  fingers  ex- 


500 


OBTEOFEDIC  SUBGEBY. 


Fig.  330. 


tended,  should  be  supported  on  the  chest  beneath  the  clothing. 
When  the  primary  sensitiveness  has  subsided,  each  of  the  joints 
of  the  extremity  should  be  moved  systematically  to  the  limit  of 
the  normal  range  of  motion  several  times  in  a  day.  For  ex- 
ample, the  humerus  should  be  hyperextended  and  rotated  out- 
ward at  the  shoulder ;  the  forearm  should  be  supinated  and  the 

wrist  and  fingers  should  be 
extended,  if  they  are  involved 
in  the  paralysis.  The  mus- 
cles should  be  massaged,  and 
the  arm  should  be  supported 
by  a  sling,  or  otherwise,  in 
proper  position.  Recovery 
may  be  complete,  although  it 
is  often  delayed  for  many 
months.  As  a  rule,  traces  of 
the  injury  are  evident  in 
atrophy  of  muscles,  particu- 
larly of  the  deltoid,  and  a 
certain  weakness  of  the  arm 
persists,  even  though  no  ac- 
tual paralysis  remains. 

In  many  instances  recov- 
ery is  but  partial,  the  arm  is 
weak,  certain  muscles  are 
paralyzed,  and  there  is  much 
restriction  of  movement  at 
the  shoulder.  The  growth  of 
the  member  is  retarded,  and 
as  has  been  mentioned,  the 
attitude  is  that  characteristic 
of  posterior  dislocation.  Xot  infrequently,  although  the  actual 
paralysis  is  slight,  the  disability  is  extreme  because  of  the  dis- 
placement which  restricts  movement  and  causes  deformity. 
The  first  essential  in  treatment,  therefore,  is  to  replace  the 
head  of  the  humerus  in  the  proper  position.  This  ajDplies  to  the 
congenital  as  well  as  to  the  acquired  disability. 

Reduction  of  Deformity.. — The  principles  of  the  treatment  of 
the  displaced  humerus  are  to  reduce  the  deformity,  to  fix  the 
part  for  a  time  sufficient  to  prevent  relapse,  to  restore  function 
as  far  as  may  be  by  .systematic  passive  motion,  and  by  exercise. 
The  method  employed  l)y  the  author  with  success  is  somewhat 


The  characteristic  attitude  of  obstetrical 
paralysis    in    infancy. 


DEFORMITIES    OF    THE    UPPER    EXTREMITY. 


501 


Fig.  331. 


similar  to  the  Lorenz  treatment  of  congenital  dislocation  at  the 
hip.^ 

The  child  having  been  anaesthetized,  is  brought  to  the  edge 
of  the  table.  The  shoulder  is  grasped  firmly  with  one  hand  in 
order  to  restrain  the  movements  of  the  scapula,  and  with  the 
other  the  arm  is  drawn  upward  and  backward  over  the  fulcrum 
of  the  thumb,  which  lies  behind 
the  joint.  This,  the  so-called 
pump-handle  movement,  alter- 
nately relaxing  and  stretching 
the  contracted  parts,  is  carried  out 
over  and  over  again  with  slowly 
increasing  force,  the  aim  being 
to  force  the  head  of  the  bone  for- 
ward, and  thus  to  thoroughly 
stretch  the  anterior  part  of  the 
capsule.  When  this  has  been 
accomplished,  there  is  a  distinct 
depression  behind,  and  the  head 
of  the  humerus  j)rojects  in  front, 
at  a  point  below  its  proper  posi- 
tion. 

One  then  attempts  to  over- 
come the  abduction  and  to  force 
the  head  upward  by  changing  the 
grasp  on  the  scapula  and  using 
the  thumb  in  the  axilla  as  a  ful- 
crum. When  the  arm  can  be 
carried  across  the  chest  to  the 
normal  degree  of  adduction,  the 
final,  and  often  most  difiicult, 
part  of  the  process,  namely,  to 
stretch  the  tissues  sufficiently  to 
permit  the  proper  degree  of  out- 
ward rotation,  is  undertaken.  This  is  best  accomplished  by 
flexing  the  forearm  and  using  this  to  exert  leverage  on  the 
humerus,  care  being  taken,  of  course,  to  avoid  the  danger  of 
fracture.  When  the  head  of  the  bone  has  been  replaced,  it  will 
be  noted  that  the  tension  on  the  anterior  tissues  causes  flexioni 
of  the  forearm;  this  must  be  overcome  in  the  same  manner,, 
and,  finally,  the  limitation  to  complete  supination.      The  ex- 

^  Whitman,  Annals  of  Surgery,  July,  1905. 


Typical  subluxation  at  the; 
shoulder  caused  by  injury  at  birth.. 
The  patient  was  treated  success- 
fully  by   the   method   described. 


502 


OBTEOPEDIC  SUBGEBY. 


tremity  is  then  fixed  in  the  over-corrected  attitude  by  means 
of  a  plaster  support  which  includes  the  thorax.  That  is,  the 
arm  is  drawn  backward  so  that  the  head  of  the  humerus  is 
made  prominent  anteriorly,  the  forearm  is  flexed  and  turned 
outward  to  the  frontal  plane,  while  the  hand  is  placed  in  ex- 
treme   supination,    the    upper   arm   lying   against    the   lateral 

thoracic  wall. 

Fig.  332. 


The  deformity  of  obstetrical  paralysis  in  adolescence. 


In  the  very  resistant  cases  it  is  impracticable  to  complete  the 
operation  at  one  sitting.  When,  therefore,  as  much  force  has 
been  exercised  as  seems  wise,  a  plaster  bandage  is  applied  to 
hold  the  arm  in  an  intermediate  position  with  the  head  of  the 
femur  forced  forward,  and  after  an  interval  of  two  or  more 
weeks  the  further  correction  is  undertaken.  In  the  treatment  of 
older  subjects  the  forcible  manipulation  may  be  preceded  or 


DEFORMITIES  OF  THE  UPPER  EXTREMITY.  503 

supplemented  by  division  of  resistant  parts.  This,  however,  is 
not  usually  necessary. 

As  has  been  stated  when  the  head  of  the  bone  is  forced  for- 
ward a  distinct  depression  and  evident  relaxation  of  the  tissues 
is  noted  on  the  posterior  aspect  of  the  joint.  The  object  of  the 
fixation  is  to  allow  the  contraction  of  the  posterior  wall  of  the 
capsule  and  the  obliteration  of  the  old  articulation,  consequently, 
the  part  must  be  fixed  for  a  period  of  at  least  three  months. 
When  the  plaster  bandage  is  removed,  the  after-treatment  is  of 
great  importance.  This  consists  of  daily  passive  forcible  move- 
ments to  the  extreme  limits  in  the  directions  formerly  re- 
stricted ;  namely,  outward  rotation,  backward  extension,  and 
eventually  abduction  of  the  humerus  and  supination  and  ex- 
tension of  the  forearm.  For  in  all  these  cases  there'  is  a  strong 
tendency  to  a  return  in  some  degree  to  the  original  posture. 
When  motion  has  become  fairly  free,  the  disabled  member  must 
be  regularly  exercised  and  re-educated  in  functional  use.  Under 
this  treatment  the  weakened  and  almost  completely  atrophied 
muscles  usually  gain  surprisingly  in  power  and  ability,  and  the 
longer  it  is  continued  the  better  will  be  the  final  result.  Even 
if  the  muscles  about  the  shoulder  are  paralyzed  the  ability  and 
appearance  of  the  arm  are  greatly  improved  by  the  reduction 
of  the  deformity. 

Repair  of  Obstetrical  Injury  to  the  Brachial  Plexus, — It  is  evi- 
dent that  if  repair  of  the  ruptured  or  otherwise  injured  cords 
of  the  brachial  plexus  does  not  take  place,  recovery  is  impos- 
sible. If  then  the  paralysis  persists,  direct  operative  interven- 
tion may  be  indicated  in  selected  cases. 

Kennedy^  has  operated  on  a  number  of  cases  for  this  purpose, 
in  one  instance  as  early  as  two  months  after  birth. 

His  method  as  modified  slightly  by  A.  S.  Taylor^  is  described 
by  the  latter  as  follows : 

The  patient  is  anaesthetized  and  brought  to  the  table  with  the 
field  prepared  for  operation.  A  firm  cushion  is  placed  beneath 
the  shoulders,  the  neck  is  moderately  extended  and  the  face 
turned  to  the  sound  side.  The  incision  passes  from  the  posterior 
border  of  the  sternomastoid  muscle,  at  the  junction  of  its  middle 
and  lower  thirds,  downward  and  outward  to  the  clavicle  at  the 
junction  of  its  middle  and  outer  thirds.  After  the  skin, 
platysma  and  deep  fascia  are  divided,  the  omohyoid  muscle  is 

^  Brit.  Med.  Jour.,  1903,  p.  298. 

=  A.  S.  Taylor,  J.  Am.  Med.  Assn.,  Vol.  48,  No.  2. 


504 


OETHOPEDIC  SUEGEPiT. 


exposed  near  the  clavicle,  and  lying  beneath  it  are  the  supra- 
scapular vessels.  These  structures  may  be  retracted  downward, 
or,  if  the  case  requires  the  extra  room,  the  omohyoid  may  be 
divided,  and  then  the  vessels  cut  between  double  ligatures.  The 
transversalis  colli  vessels  are  seen  a  little  below  the  middle  of 
the  wound  and  are  divided  between  double  ligatures. 

The  dissection  is  rapidly  carried  through  the  fat  layer  to  the 
deep  cervical  fascia  covering  the  brachial  plexus,  which  fascia 
is  usually  thickened  and  adherent  to  the  damaged  nerve  roots. 
This  fascia  is  divided  in  the  line  of  the  original  incision  and 
is  dissected  away  for  the  free  exposure  of  the  nerves    (Fig. 

Fig.  333. 


Operation  for  relief  of  brachial  paralysis.  (Taylor.)  A,  scalenus  anticus 
muscle.  B,  phrenic  nerve.  C,  internal  jugular  vein.  D,  transversalis  colli 
artery.  E,  seventh  root.  F,  omohyoid  muscle.  G,  fifth  root.  H,  scalenus 
medius  muscle.  I,  sixth  root.  ./,  transversalis  colli  artery.  K.  suprascapular 
nerve.     L,  external  anterior  thoracic  nerve.      AI,  clavicle.     X,  nerve  to  subclavius. 


333).  The  damaged  nerves  are  usually  noticeably  thickened 
and  of  greater  density  than  normal  nerves.  The  extent  and 
distribution  of  the  paralysis,  determined  before  operation,  gives 
the  clue  as  to  which  nerves  are  at  fault.  Usually  the  junction 
of  the  fifth  and  sixth  roots  is  the  site  of  maximum  damage. 
The  thickened  indurated   areas   are   determined  by   palpation 


DEFOBMITIES  OF  TEE  UPPEE  EXTEEMITY.  505 

and  are  excised  bj  means  of  a  sharp  scalpel.  Scissors  should 
never  be  used  for  this  work. 

The  nerve  ends  are  brought  into  apposition  by  lateral  sutures 
of  fine  silk  involving  the  nerve  sheaths  only,  while  the  neck  and 
shoulder  are  approximated  to  prevent  tension  on  the  sutures. 
Cargile  membrane  is  wrapped  about  the  anastomosis  to  prevent 
connective  tissue  ingTowth.  The  omohyoid  muscle,  if  divided, 
is  sutured.  The  wound  is  closed  with  silk.  A  firm  sterile 
dressing  is  apjjlied,  and  a  bandage  is  applied  to  approximate 
head  and  shoulder  so  as  to  prevent  tension  on  the  nerve  sutures. 
This  position  must  be  maintained  for  at  least  three  weeks.  The 
most  feasible  method  of  accomplishing  this  result  is  a  plaster- 
of-Paris  support  placed  on  the  child  and  allowed  to  harden  in 
the  proper  position  before  operation.  It  is  then  trimmed  and 
removed.  When  the  nerve  suturing  is  finished  the  sjDlint  is 
slipped  on,  the  wound  is  then  closed,  the  dressings  applied,  and 
the  child  put  to  bed  without  danger  of  pulling  the  nerve  ends 
apart. 

It  will  be  noticed  (Fig.  333)  that  (a)  the  tissues  to  be  ex- 
cised lie  in  close  proximity  to  the  phrenic  nerve  and  internal 
jugular  vein,  and  to  the  junction  of  the  cervical  sympathetic 
communications  with  the  spinal  nerve  roots.  (5)  The  supra- 
scapular nerve  comes  oif  from  the  junction  of  the  fifth  and  sixth 
cervical  nerve  roots,  which  as  already  stated,  is  usually  the  site 
of  maximum  damage.  This  nerve  is  very  small  in  children, 
but  it  should  be  sutured  with  the  gTeatest  care,  since  it  in- 
nervates the  external  rotators  of  the  humerus,  the  paralysis  of 
which  permits  the  posterior  dislocation  of  the  shoulder  often 
seen  in  the  older  cases. 

If  the  deformity  is  of  long  standing,  operations  on  the  in- 
jured nerves  of  somewhat  doubtful  utility  at  best  can  have  no 
influence  on  the  disability  unless  distortions  and  contractions 
have  been  previously  overcome  in  the  manner  already  described. 

RECURRENT  DISLOCATION  OF  THE  SHOULDER. 

Recurrent  dislocation  of  the  shoulder  is  in  most  instances  a 
sequel  of  traumatic  dislocation.  The  cause  of  the  instability  is 
usually  laxity  of  the  capsular  ligament  and  weakness  of  the  sup- 
porting muscles,  the  result,  it  may  be,  of  too  early  use  of  the  arm 
after  the  accident.  In  rare  instances  greater  derangement  of  the 
joint  caused  by  fracture  of  one  or  other  of  the  articulating  sur- 


506 


OETEOPEDIC  SUBGEBY. 


faces,  rupture  or  displacement  of  ligaments  or  muscles,  or  per- 
manent paralysis  of  the  deltoid  muscle  may  be  present. 

The  displacement,  which  may  be  partial  or  complete,  recurs  at 
intervals  and  is  a  very  serious  disability. 

Treatment.- — If  the  patient  is  seen  immediately  after  a  dis- 
placement and  if  the  dislocation  has  recurred  but  a  few  times 
and  at  long  intervals,  it  may  be  inferred  that  the  disability  is 
the  result  of  simple  laxity  of  the  capsule  and  of  muscular  weak- 
ness.    In  such  cases  a  period  of  fixation  followed  by  massage 


Fig.  334 


Bilateral    congenital   pronation   of  the  forearms. 


and  exercise  of  the  atrophied  muscles  may  result  in  cure.  The 
patient  should  be  carefully  questioned  as  to  the  particular  move- 
ments of  the  arm  that  are  likely  to  cause  the  displacement, 
which  is,  as  a  rule,  forward  beneath  the  coracoid  process.  Most 
often  elevation  and  abduction  seem  to  be  the  predisposing  move- 
ments that  should  be  restrained.    A  simple  and  often  an  effective 


DEFORMITIES    OF    THE    UPPEB    EXTREMITY.  507 

means  of  treatment  is  the  application  of  a  shoulder-cap  of 
canvas  that  fits  closely  about  the  shoulder  and  upper  arm.  This 
is  held  in  place  by  bands  crossing  the  body  and  buckled  beneath 
the  other  arm;  from  the  lower  border  of  the  cap  one  or  more 
bands  pass  downward  and  are  attached  with  the  braces  to  the 
trousers,  so  that  elevation  of  the  arm  is  restrained,  before  the 
point  of  instability  is  reached. 

Operative..^ — If  these  milder  measures  are  ineffective,  an  opera- 
tion to  reduce  the  size  of  the  lax  capsule  may  be  performed. 
The  arm  being  slightly  abducted,  an  incision  is  made  from  the 
coracoid  process  downward  and  outward  along  the  line  of  the 
cephalic  vein  to  a  point  below  the  upper  border  of  the  tendinous 
insertion  of  the  pectoralis  major.  The  deltoid  and  the  pectoralis 
major  are  separated,  exposing  in  the  upper  border  of  the  wound 
the  coracobrachialis,  and  in  the  lower  angle  the  upper  part, of 
the  insertion  of  the  pectoralis  major  muscles.  The  upper  three- 
fourths  of  this  insertion  is  divided  in  order  to  expose  the  head 
and  neck  of  the  bone.  The  humerus  is  then  rotated  outward  and 
a  portion  of  the  insertion  of  the  subscapularis  muscle,  stretched 
over  the  head  of  the  humerus,  is  divided.  The  capsule  is  thus 
laid  bare,  and  a  sufficient  section  is  removed  to  overcome  the 
laxity.    The  wound  is  then  closed. 

Similar  operations  in  which  the  lax  caj)sule  was  overlapped 
and  sutured  without  opening  it  have  been  performed,  by  Ricard 
in  1892  and  by  Steinthal  in  1895.^ 

CONGENITAL  DEFORMITIES  OF  THE  ELBOW. 

Congenital  displacement  of  the  ulna  is  one  of  the  rarest  of 
deformities.  The  displacement  is  usually  incomplete,  and  it  is 
associated  with  laxity  of  the  ligaments. 

Congenital  displacement  of  the  radius  is  much  more  common, 
53  cases  having  been  reported.^ 

In  many  instances  the  head  of  the  radius  is  disj)laced  back- 
ward; thus  the  forearm  is  pronated  and  extension  is  usually 
limited.  In  some  cases  a  certain  range  of  pronation  and  supi- 
nation is  present  but  in  others  the  two  bones  are  joined  by  bony 
growth  (Fig.  334).  Excision  of  the  head  of  the  radius,  separa- 
tion of  the  bones,  fixation  for  a  time  in  the  attitude  of  supina- 
tion followed  by  passive  motion,  and  exercises  would  be  indi- 
cated in  operative  treatment. 

^Burrell  and  Lovett,  American  Journal  of  the  Medical  Sciences,  August, 
1897. 

^  Blodgett,  Amer.  Journ.  Ortli.  Surg..  January,  1906. 


508  OETHOPEDIC  SrHGEBY. 

CONGENITAL  PRONATION  OF  THE  FOREARM. 

This  deformity  is  usually  bilateral  and  it  is  often  an  accom- 
paniment of  ftision  of  the  tipper  extremities  of  the  radius  and 
ulna,  usually  to  the  extent  of  about  two  inches  (Fig.  334). 

Treatment.- — The  bones  may  be  cut  apart  with  a  chisel  and 
separated  by  the  insertion  of  a  flap  of  fibromtiscular  tissue.  If 
the  head  of  the  radius  is  fixed  it  may  be  removed  or  the  bone 
may  be  divided  at  its  neck.  The  attitude  may  be  improved  by 
operative  treatment  and  in  favorable  cases  some  motion  may  be 
regained. 

CUBITUS  VALGUS,    CUBITUS  VARUS. 

Cubitus  valgus,  in  which  the  forearm  is  abducted  at  the  elbow 
and  cubitus  varus,  in  which  it  is  inclined  in  the  other  direction, 
are  occasionally  seen  as  congenital  deformities.  They  are,  in 
most  instances,  associated  with  laxity  of  the  ligaments. 

Similar  deformities  are  not  uncommon  during  the  progressive 
stage  of  rhachitis,  but  they  usually  disappear  after  the  erect 
attitude  is  assumed. 

The  supinated  forearm  forms  an  angle  with  the  upper  arm, 
opening  outward  when  the  limb  is  extended  at  about  173  de- 
grees in  males  and  167  degrees  in  females.^  This  is  sometimes 
called  the  "  carrying "  angle,  because  the  hand  is  held  at  some 
distance  from  the  body  while  the  arm  is  in  contact  with  the 
trunk.  The  angle  is  caused  by  the  obliquity  of  the  ulno- 
humeral  joint  and  it  is  not  apparent  when  the  forearm  is  pro- 
nated.  What  may  be  called  normal  cubitus  valgus  is  common 
among  women,  and  in  certain  instances  it  may  be  exaggerated 
to  deformity.  Acquired  cubitus  varus  is  usually  the  result  of 
direct  injury.  Both  deformities  may  be  treated  by  osteotomy  of 
ihe  humerus  just  above  the  articulation  after  the  method  used 
to  correct  similar  deformity  at  the  knee.  If  in  addition  to  the 
lateral  deformity  motion  is  restricted  by  displaced  fragments  of 
bone  or  by  exuberent  callus  it  is  advisable  to  open  the  joint  for 
the  purpose  of  removing  the  obstructions.  After  operation  for 
the  correction  of  lateral  deformity  if  the  patient  is  to  walk 
about  the  arm  should  be  fixed  in  full  extension  and  supination 
by  a  shoulder  spica  plaster  bandage,  the  limb  being  elevated. 
Thus  the  danger  of  swelling  and  constriction,  almost  inevitable 
if  the  limb  is  pendant,  may  be  avoided  (Fig.  325). 

^  Potter    Journal  of  Anatomv  and  Physiology-,  vol.  xxix.,  p.  488. 


DEFORMITIES    OF    THE    UPPER    EXTREMITY.  509 

Fig.  335. 


The  shoulder  spica.  This  support  is  used  after  correction  of  lateral  de- 
formity at  the  elbow  and  in  the  treatment  of  fractures  with  lateral  distortion. 
The  same  support  is  used  in  the  treatment  of  epiphyseal  fracture  at  the 
shoulder,  the  fragments  being  held  in  apposition  by  fixing  the  arm  in  a  nearly 
perpendicular  attitude  with  forward  inclination.  Whitman,  Annals  of  Surgery, 
May,  1908. 

SUBLUXATION   OF   THE  WRIST. 

A  peculiar  displacement  of  the  hand  forward  and  usually 
toward  the  radial  side,  first  noted  by  Malgaigne  and  described  by 
Madelung^  as  "  spontaneous  subluxation,"  is  sometimes  seen  in 
young  subjects.  In  these  cases  the  lower  extremity  of  the  ulna 
is  displaced  toward  the  dorsum  of  the  hand;  there  is  abnormal 
separation  of  the  two  bones  of  the  forearm  from  one  another  at 
the  wrist,  and  in  many  instances  the  lower  extremity  of  the 
radius  is  bent  forward.  As  a  consequence  the  wrist  is  enlarged, 
the  ligaments  are  relaxed,  and  dorsal  flexion  of  the  hand  is 
restricted  and  if  the  deformity  is  extreme,  pronation  and  supi- 

^  Archiv  f .  klin.  Chir.,  Bd.   xxiii. 


510  OETHOPEDIC  SUBGEEY. 

nation  also.  Destot  suggests  the  term  curved  radius  as  more 
properly  descriptive  of  the  affection  as  there  is  no  subluxation 
excejDt  in  extreme  cases.  Lenormant^  has  collected  47  cases  from 
literature.  Twenty-three  were  bilateral,  24  were  unilateral  (12 
of  the  left,  9  of  the  right,  3  unspecified).  The  symptoms,  aside 
from  the  deformity  and  limitation  of  motion,  are  weakness  and 
sensations  of  discomfort  about  the  dorsum  of  the  wrist. 

Fig.  336. 


"  Spontaneous   subluxation   of   the   wrist." 

Etiology.- — The  deformity  most  often  develops  in  later  child- 
hood and  adolescence.  The  predisposing  causes  of  the  affection 
are,  apparently,  relaxation  of  the  ligaments,  and,  probably, 
slight  pre-existing  rhachitic  deformity  of  the  same  character. 
The  exciting  causes  are  occupation  and  injury. 

Treatment. — The  treatment  is  rest,  massage,  forcible  manipu- 
lation in  the  direction  of  extension,  and  a  suj)port  of  leather  or 
other  material  to  hold  the  hand  in  the  extended  position.  In 
well  marked  cases  the  deformity  of  the  radius  should  be  cor- 
rected by  osteotomy.  Deformities  of  the  hand  due  to  over- 
growth of  one  or  other  of  the  bones  of  the  forearm  or  to  loss 
of  growth  caused  by  disease  or  operative  treatment  are  occasion- 
ally seen.  Radical  operations  in  early  life  which  involve  re- 
moval of  growing  bone  should  always  be  avoided. 

CONGENITAL  DEFORMITIES  AT  THE  WRIST. 

Simple  congenital  dislocation  at  the  wrist  is  extremely  rare. 
Displacement  of  the  wrist  and  hand  is  usually  associated  with 
defective  development  of  the  bones  of  the  arm,  and  the  de- 
formity is  usually  classed  as  club-hand. 

^Eevue  d'Orthop.,  Jan.,  1907. 


DEFOEMITIES    OF    TEE    UPPEB    EXTBEMITY. 


511 


CLUB-HAND. 

Congenital  distortions  of  the  hand  may  be  divided  into  four 
primary  varieties,  according  to  the  direction  in  w^hich  the  hand 
is  turned,  viz. : 

1.  Forvi^ard  or  palmar. 

2.  Backward  or  dorsal. 

3.  Lateral  to  the  radial  side — radial. 

4.  Lateral  to  the  ulnar  side^ — ulnar. 

Lateral  and  anteroposterior  distortions  occur  also  in  combina- 
tion. 

Etiology.- — There  are  two  distinct  varieties  of  club-hand: 

Fig.  337. 


Club-hands  and  club-feet. 


1.  In  which  there  is  simple  distortion  caused  apparently  by 
abnormal  restraint  and  pressure  in  utero.  In  certain  cases  of 
this  class  there  may  be  limited  motion  at  both  the  shoulder  and 
elbow-joints  and  defective  muscular  development,  apparently 
dependent  upon  long-continued  fixation. 

2.  In  which  the  deformity  is  associated  with  defective  devel- 
opment of  the  radius  or  ulna  and  often  with  congenital  ab- 
normalities of  other  parts. 


512 


OBTHOPEDIC  SUBGEBY. 


In  tlie  palmar  and  dorsal  distortions  the  bones  of  the  arm  are 
usually  normal.  The  lateral  deviations  of  the  hand  are  often 
complicated  by  defective  formation  of  the  radius  or  ulna,  and 
as  in  talipes  due  to  absence  of  the  tibia  or  fibula  the  hand  may 
be  malformed  also. 

Deficient  formation  of  the  radius  with  corresponding  distor- 
tion is  the  most  common.  Of  this  114  cases  are  recorded.  In 
56  cases  it  was  stated  that  the  deformity  was  unilateral,  in  46 
bilateral.  In  44  cases  the  radius  was  absent;  in  12  cases  a  part 
was  present ;  60  per  cent,  of  the  patients  were  males.^ 

The  most  important  form  of  club-hand  is,  then,  that  due  to 
absence  or  to  defective  formation  of  the  radius.  As  in  talipes 
valgus  due  to  absence  of  the  fibula,  the  tibia  is  short  and  often 
bent  sharply  forward,  so  in  this  form  of  club-hand  the  ulna  is 
usually  short  and  bent  inward.  The  hand  may  be  perfect  in 
formation,  but,  as  a  rule,  the  thumb  is  absent  or  rudimentary, 
and  other  adjoining  bones,  together  with  the  corresponding 
ligaments  and  muscles,  may  be  absent  also^  (^ig-  338). 

The  hand  occupies  practically  a  right-angled  relation  to  the 
ulna,  and  as  this  bone  is  usually  bent  inward  as  well,  the  direc- 

FiG.  338. 


Congenital  absence  of  radius  and  the  bones  of  the  thumb.      (Weigel.) 


^Antonelli,  Zeits.  f.  Orth.  Chir.,  1905,  Bd.  xiv. 

^  StofPel  u.  Stempel,  Zeits.  f .  Orth.  Chir.,  B.  23,  H.  1  u.  2,  1909. 


DEFORMITIES    OF    TEE    UPPER    EXTREMITY. 


513 


Fig.  339. 


tion  of  the  hand  is  often  reversed  and  is  parallel  to  the  forearm. 
As  a  rule,  the  hand  is  also  somewhat  bent  forward,  so  that  the 
deformity  might  be  described  as  radiopalmar  (Fig.  339). 

Treatment. — In  those  forms  of 
club-hand  in  which  the  structure 
is  normal  the  deformity  may  be 
overcome,  as  a  rule,  by  manipula- 
tion, and  support  by  the  plaster 
bandage  or  otherwise,  as  described 
in  the  treatment  of  talipes.  Mas- 
sage and  muscle  training  are  re- 
quired in  the  after-treatment.  If 
the  deformity  is  complicated  by 
defective  muscular  development 
and  limited  joint  motion  massage 
and  passive  manipulation  may  be 
required  for  years.  Complete  re- 
covery is  unusual. 

In  slighter  cases  of  radial  club- 
hand, due  to  defective  develop- 
ment, it  may  be  possible  by  manip- 
ulation and  tenotomy  to  replace 
the  hand  in  its  normal  position, 
but  this  is  unusual.  After  division 
of  the  contracted  tissues,  Sayre^ 
removed  a  portion  of  the  carpus 
and  implanted  the  head  of  the 
ulna  at  the  point  of  resection. 
McCurdy^  sawed  through  the 
ulna,  leaving  the  extremity  in  re- 
lation to  the  carpus  and  sutured 
the  proximal  fragment  and  the 
semilunar  bone  to  one  another. 
Thomson^  replaced  the  hand  by 
subcutaneous  tenotomy  and  by  the  removal  of  a  cuneiform 
section  of  bone  from  the  lower  end  of  the  ulna. 

The  operation  of  splitting  the  ulna  into  an  ulnar  and  radial 
portion  and  implanting  the  carpus  between  the  two  has  been 
jDerformed   by    Bardenheuer.*      The    immediate    effect    of   the 

^  Transactions  American  Orthopedic  Association,  vol.  vi. 
^  Ibid.,  vol.  viii. 

^  Transactions  American  Orthopedic  Association,  vol.  ix. 
'  Verhand.  der  deutsch.  Gesells.  f.  Chir.,  23  Kong.,  1894. 

33 


congenital  club-hands,  showing 
the  short  and  deformed  forearms, 
also   bow-legs.       (Gibney.) 


514  OBTHOPEDIC  SUEGEBY. 

various  operative  procedures  was  favorable,  but  no  final  results 
have  been  reported. 

In  any  event  some  form  of  apparatus  must  be  used  during 
childhood  at  least,  to  support  the  hand,  whether  the  operation 
has  been  successful  or  not.  It  is  therefore  better  to  defer  radical 
treatment ;  at  best  the  arm  will  be  short  and  the  defective  hand 
will  be  weak  as  compared  with  the  normal, 

CONTRACTIONS  AND  DISTORTIONS  OF  THE  FINGERS. 

Congenital  Contraction  of  the  Fingers. — The  most  common 
form  of  congenital  contraction  and  one  that  is  sometimes  hered- 
itary is  that  of  the  little  finger  (hammer  finger)  of  one  or  both 
hands.  This  is  semiflexed  and  extension  is  checked  by  what 
appears  to  be  a  congenital  shortening  of  all  the  soft  parts  on  the 
flexor  side.  In  other  instances  several  fingers  may  be  similarly 
affected. 

Treatment. — If  treatment  by  manipulation  and  splinting  is 
begun  early  the  deformity  may  be  overcome  by  lengthening  the 
contracted  tissue.  In  later  life  the  prospect  of  perfect  cure  by 
any  method  of  treatment  is  slight,  because  of  the  strong  tendency 
to  recontraction  after  the  finger  has  been  straightened. 

Webbed  Fingers. ^ — In  the  most  common  form  of  this  deform- 
ity two  or  more  fingers  are  joined  by  skin  and  fibrous  tissue  to 
the  first  phalangeal  joints,  but  sometimes  throughout  the  entire 
length  of  the  fingers. 

In  other  instances  the  web  may  be  thicker,  containing  muscu- 
lar fibres  from,  the  apposed  parts,  and,  occasionally,  the  bones 
of  the  two  fingers  may  be  joined  to  one  another,  even  to  the 
finger-nails. 

Etiology-r — The  cause  of  the  deformity  is  arrest  of  develop- 
ment before  the  fingers  have  been  separated  from  one  another ; 
thus  the  thumb,  which  is  differentiated  from  the  other  parts  of 
the  hand  as  early  as  the  seventy-fifth  day  of  intrauterine  life,  is 
rarely  involved,  as  compared  with  the  fingers,  which  are  sep- 
arated from  one  another  at  a  later  period. 

Treatment. — In  all  but  the  extreme  grades  of  deformity  the 
fingers  may  be  separated  from  one  another,  operative  treatment 
being  conducted  according  to  the  rules  of  plastic  surgery. 

Congenital  Displacements  of  the  Phalanges  and  Distortions 
of  the  Fingers. — These  deformities  are  not  particularly  uncom- 
mon.    They  should  be  treated  by  manipulation  and  by  splinting 


DEFOBMITIES    OF    THE    UPPER    EXTREMITY.  515 

at  as  early  a  period  as  is  practicable.  Other  congenital  de- 
formities and  malformations  of  the  hand  do  not  call  for  ex- 
tended comment. 

Trigger  Finger Synonyms. — Jerking  finger,  snapping  finger. 

This  aft'ection  was  first  described  by  ^elaton  under  the  title 
"  Doigt  a  Ressort."  On  extending  the  closed  hand  one  finger 
remains  flexed.  If  the  flexion  is  overcome  by  greater  muscular 
effort  or  by  passive  force  the  finger  flies  back  to  complete  ex- 
tension with  a  sudden  snap  or  jerk;  hence  the  name.  In  well- 
marked  cases  the  same  difficulty  and  the  subsequent  snap 
occurs  on  flexing  the  finger.  The  middle  and  ring  fingers  are 
more  often  affected,  but  sometimes  the  thumb  or  the  other  fingers 
may  be  involved. 

The  patient  usually  complains  somewhat  of  stiffness  and  pain 
in  the  finger,  but  the  interference  with  its  function  is  the  prin- 
cipal symptom. 

Etiology.- — The  cause  of  the  disability  is  interference  with  the 
motion  of  the  tendon  in  its  fibrous  sheath,  either  because  of  a 
reduction  of  its  calibre  due  to  injury  or  inflammation,  or  to  an 
enlargement  or  irregularity  of  the  tendon  itself.  In  most  in- 
stances the  obstruction  appears  to  be  in  the  neighborhood  of  the 
metatarsophalangeal  joint. -^ 

The  duration  of  the  affection  is  indefinite. 

Treatment. — If  the  obstruction  appears  to  be  of  inflammatory 
or  traumatic  origin  it  may  be  treated  by  splinting  and  later  by 
massage.  In  confirmed  cases  the  tendon  and  the  sheath  may  be 
explored  in  the  hope  of  finding  and  removing  the  obstruction.^ 
The  incision  should  be  made  on  the  point  at  which  the  sensation, 
of  obstruction  is  referred.  As  a  rule,  it  is  only  necessary  ta 
split  the  sheath.^ 

Mallet  Finger Synonym. — Drop-finger. 

This  is  caused  usually  by  a  blow  upon  the  terminal  phalanx, 
which  ruptures  or  weakens  the  attachment  of  the  extensor  ten- 
don at  the  base  of  the  phalanx  so  that  it  is  habitually  flexed 
sometimes  nearly  to  a  right  angle. 

The  treatment  must  be  by  incision  and  re-attachment  of  the 
tendon  to  the  periosteum, 

"  Baseball  finger  "  is  the  reverse  displacement  of  the  terminal 
phalanx,  which  is  dislocated  backward,  forming  a  bayonet-like 

^  Marches,  Deutsche  Zeits.  f .  Chir.,  Bd.  Ixxix.,  p.  364. 

-  The  bibliography  is  large.  More  recent  articles  are  those  of  Jamin, 
Cent.  f.  Chir.,  June  6,  1896,  who  reports  thirty-one  cases,  and  A.  Necker, 
Beitrage  zur  klin.  Chir.,  B.  x.,  p.  469. 

^Weir,  J.  Am.  Med.  Assn.,  Oct.  5,  1907. 


516  OETROPEDIC  SUEGEBY. 

deformity.  There  is  often,  in  addition,  injury  of  the  base  of 
the  phalanx  that  causes  subsequent  irregular  hypertrophy. 

If  reposition  is  impossible  open  incision  may  be  employed  to 
correct  the  deformity. 

Dupuytren's  Contraction. — Dupuytren's  contraction  is  a  de- 
formity of  the  hand  caused  by  contraction  of  a  part  of  the 
palmar  fascia  and  of  its  prolongations  to  one  or  more  of  the 
fingers.  The  fingers  are  flexed  as  a  consequence  to  a  greater  or 
less  degree,  and  in  advanced  cases  they  may  be  drawn  to  close 
contact  with  the  palm.  The  ring  finger  is  most  often  primarily 
affected,  but,  as  a  rule,  two  or  more  fingers  are  somewhat  in- 
volved in  the  contraction. 

In  a  large  proportion  of  the  cases  both  hands  are  affected, 
but  not  as  a  rule  simultaneously,  the  contraction  beginning  in 
the  second  hand  several  years  after  the  deformity  in  the  first. 

Pathology.. — The  characteristics  of  the  deformity  are  explained 
by  the  anatomy  of  the  palmar  fascia.  This  consists  of  a  strong 
central  portion,  and  two  thinner  lateral  parts  that  cover  the  mus- 
cles of  the  thumb  and  little  finger.  It  is  made  up  of  longitu- 
dinal fibres  continuous  with  the  tendon  of  the  palmaris  longiis, 
and  the  annular  ligaments.  It  divides  into  four  processes  that 
are  attached  to  the  digital  sheaths,  to  the  integaiment  at  the 
clefts  of  the  fingers,  and  to  the  superficial  transverse  ligament. 
Prolongations  of  the  fascia  pass  along  the  lateral  aspect  of  the 
fingers  and  are  attached  to  the  periosteum  and  to  the  tendon 
sheaths  of  the  first  and  second  phalanges. 

The  cause  of  the  contraction  appears  to  be  a  chronic  plastic 
inflammation  of  a  part  of  the  fascia,  which  becomes  hypertro- 
phied  and  flnally  contracts,  drawing  the  flnger  toward  the  palm 
in  the  manner  described. 

Etiology. — The  etiology  is  uncertain. 

The  contraction  is  much  more  common  in  men  than  in 
women,  and  it  is  practically  confined  to  middle  and  later  life. 
It  is  claimed  that  the  deformity  is  more  common  among  those 
who  are  subject  to  gout  or  rheumatism.  It  appears,  also,  to  be 
an  hereditary  affection  in  certain  instances.  Injury  or  irrita- 
tion of  the  palmar  tissues,  incident  to  certain  occupations, 
would  seem  to  explain  the  disproportionate  liability  of  the  sexes 
to  the  affection. 

Symptoms.. — The  first  symptom  is  usually  the  deformity;  the 
patient  finds  it  impossible  to  completely  extend  one  or  more  of 
the  fingers;  the  tissues  about  the  base  of  the  finger  seem  stiff', 


DEFOBMITIES    OF    THE    UPPER    EXTBEMITY.  517 

and  when  it  is  forcibly  extended  a  hard;  elevated  cord  may  be 
felt  extending  from  about  the  centre  of  the  palm  to  the  second 
phalanx,  most  prominent  at  the  metacarpophalangeal  articu- 
lation. 

To  this  the  skin  is  adherent,  and  as  the  contraction  increases 
it  is  thrown  into  elevated  ridges.  Later  other  bands  appear  if 
the  contraction  affects,  as  it  usually  does,  other  portions  of  the 
fascia.  In  many  instances  no  pain  is  experienced  unless  the 
contracted  fascia  is  forcibly  stretched  or  is  passed  upon.  In 
other  cases  complaint  is  made  of  neuralgic  pain  in  the  hand  and 
even  in  the  arm  and  back.  Occasionally  the  first  symptom  to 
attract  attention  may  be  a  sensitive  nodule  in  the  skin  at  the 
base  of  the  finger. 

The  contraction  usually  increases  slowly  until  the  finger  that 
is  most  affected  is  drawn  to  the  palm. 

Treatment. — The  deformity  may  be  overcome  in  part  by  mul- 
tiple division  of  the  contracted  bands  from  the  finger  to  the 
palm,  but  complete  removal  of  the  contracted  fascia  is  prefer- 
able if  it  be  possible.  The  finger  is  then  supported  in  an  atti- 
tude of  slight  flexion  until  the  circulation  is  adjusted  to  the  new 
position. 

ISCHEMIC  PARALYSIS  AND  CONTRACTION. 

Paralysis  and  contraction  may  follow  prolonged  constriction. 
This  is  most  often  seen  in  the  forearm  and  hand  in  young  sub- 
jects, as  a  result  of  treatment  for  fracture  about  the  elbow. 

Symptoms. — The  preliminary  symptoms  are  pain,  swelling, 
discoloration,  loss  of  sensation  and  finally  of  motion.  It  is  esti- 
mated that  moderate  constriction  for  six  hours  may  cause  par- 
alysis which,  in  cases  of  the  milder  type,  is  limited  to  the  exten- 
sor group.  If  the  hand  is  not  supported  contraction  follows. 
In  characteristic  cases  the  hand  is  flexed  on  the  forearm,  and  the 
fingers  at  the  interphalangeal  joints  are  contracted  to  a  right 
angular  attitude.  Extension  is  resisted  by  a  firm  shortening  of 
the  tissues  on  the  flexor  aspect  caused  by  fibrous  degeneration  of 
the  muscles.  The  affected  part  is  atrophied  and  cold.  Sensa- 
tion in  the  fingers  is  diminished  or  lost. 

Treatment. — Prevention. — The  possibility  of  this  complication 
should  be  borne  in  mind  when  treating  fractures  or  correcting 
deformity  at  the  elbow.  The  hand  should  be  examined  fre- 
quently and  the  patient  should  be  instructed  to  move  the  fingers 


518  ORTHOPEDIC  SUEGEBY. 

from  time  to  time.  Pain  and  swelling  indicate  the  necessity  for 
complete  relief  of  constriction.  If  paralysis  is  present  the  hand 
should  he  at  once  supported  in  hyperextension  to  prevent  con- 
traction. In  most  cases,  however,  confirmed  deformity  is  already 
present  when  the  patient  is  brought  for  treatment. 

Corrective. — The  most  efficient  method  of  treatment  is  that  of 
gradual  correction  advocated  by  Jones  of  Liverpool.  This  is 
conducted  methodically  along  the  line  of  least  resistance.  It 
may  be  noted  that  although  the  fingers  are  rigidly  contracted  at 
the  interphalangeal  joints  where  the  hand  is  extended,  the  con- 
traction is  lessened  if  the  wrist  is  flexed.  One  begins  therefore 
by  flexing  the  hand  on  the  forearm  to  relax  the  tension.  Straight 
sj)lints  are  then  applied  to  the  flexor  side  of  the  fingers  and 
from  day  to  day  more  pressure  is  applied  until  each  finger  is 
straightened.  When  this  is  accomplished  a  palmar  splint  of 
metal  bent  to  fit  the  deformity  is  a]3plied  to  the  forearm  and 
hand.  This  is  gradually  straightened  to  extend  the  splinted 
fingers  on  the  hand.  When  these  are  hyperextended,  one  begins 
in  the  same  manner  to  correct  the  flexion  at  the  wrist  until  in 
successful  cases  after  weeks  or  months  hyperextension  at  all  the 
deformed  joints  has  been  accomplished.  During  the  treatment 
the  power  in  the  extensor  group  increases  and  sensation  im- 
proves. Massage,  exercise  and  the  like  are  of  course  essential 
when  the  deformity  has  been  corrected.  Lengthening  of  the 
flexor  tendons,  removal  of  bone  to  accommodate  the  shortening 
or  other  radical  procedures  should  be  deferred  until  the  failure 
of  gradual  correction  indicates  the  necessity  for  them. 


CHAPTER    XIV. 

CONGENITAL    AND    ACQUIRED    AFFECTIONS    LEADING    TO 
GENERAL  DISTORTIONS. 

RHACHITIS. 

Synonym. — Rickets. 

Rhachitis  is  a  constitutional  disease  of  infancy  caused  by  de- 
fective nutrition,  of  which  the  most  marked  effect  is  distortion 
of  the  bones. 

Etiology. — The  predisposing  cause  is  constitutional  weakness. 
This  may  be  inherited  or  it  may  be  the  direct  effect  of  illness, 
but  most  often  it  is  the  result  of  improper  hygienic  suround- 
ings,  particularly  lack  of  sunlight,  damp  rooms  and  overcrowd- 
ing. The  direct  cause  of  the  disease  is  defective  assimilation. 
In  most  instances  this  is  due  to  the  substitution  of  artificial 
food  for  the  mother's  milk,  in  others  to  improper  diet  after  the 
infant  is  weaned;  in  rare  cases  it  may  be  the  result  of  pro- 
longed lactation,  or  it  may  be  caused  by  the  defective  quality  of 
the  mother's  milk.  The  disease,  therefore,  begins  usually  be- 
tween the  ages  of  six  and  eighteen  months,  although  it  is  by  no 
means  confined  to  these  limits.  According  to  Baginsky  the  age 
of  onset  in  623  cases  was  as  follows : 

Males.  Females.  Total. 

3-6  months 35  8  43 

6  -12  months 101  72  173 

1  -  11/2  years 115  105  220 

1%-  2  years 64  49  113 

2  -  21/^  years 18  24  42 

21^-3  years 9  12  21 

3-4  years 2  5  7 

4  -13  years __0  J)  4 

344     275      623 

In  most  instances  improper  surroundings  and  improper  nour- 
ishment are  combined  in  the  causation  of  the  disease ;  thus  rha- 
chitis  is  relatively  common  in  large  cities.  In  'New  York  the 
most  extreme  cases  are  observed  among  the  Italian  and  the 
colored  children.  The  former  are  usually  nursed,  but  are  im- 
properly fed  after  weaning,  while  the  latter,  if  nursed  at  all,  are 
usually  allowed  a  mixed  diet  even  during  the  early  months  of 
life. 

519 


520  ORTHOPEDIC  SUBGEBY. 

Pathology. — The  manifestations  of  a  disease  induced  by  im- 
paired nutrition  are,  of  course,  general  in  character.  In  rha- 
ehitis  there  is  a  mild  degree  of  aiiEemia,  and  general  weakness 
and  relaxation  of  the  voluntary  and  involuntary  muscles.  As 
a  result  the  circulation  is  impaired  and  the  power  of  assimila- 
tion is  diminished;  thus  congestion  and  enlargement  of  the 
internal  organs,  intestinal  catarrh,  bronchitis,  and  the  like  are 
common  accompaniments  of  the  disease.  The  most  marked  and 
characteristic  changes  are  in  the  bones ;  these  consist  in  a  dimi- 
nution of  the  earthy  substances  and  in  overgTOwth  of  osteoid 
tissue. 

"  The  essential  features  of  the  morbid  processes  are,  first,  an 
exaggeration  of  the  processes  immediately  preparatory  to  the 
development  of  true  bone;  secondly  an  imperfect  conversion  of 
this  preparatory  tissue  into  true  bone;  and  thirdly,  a  great 
irregularity  of  the  whole  process."     (Erichsen.) 

On  section  of  rhachitic  bone  it  will  be  noted  that  the  perios- 
teum is  increased  in  thickness,  and  is  more  or  less  adherent  to 
the  underlying  softened  and  spongy  tissue.  The  medullary 
canal  is  enlarged,  and  its  contents  are  abnormally  vascular. 
The  epiphyseal  cartilage,  normally  a  thin,  bluish  line,  is  much 
increased  in  thickness.  It  appears  to  be  swollen  and  infiltrated, 
and  it  has  lost  its  former  translucency.  Microscopic  examina- 
tion at  this  point,  where  growth  is  most  active,  shows  marked 
irregularity  in  size  and  shape  of  the  columns  of  cartilage  cells ; 
the  zone  of  calcification  is  lacking  or  is  ill-defined,  and  masses 
of  cartilage  cells  are  found  unchanged  in  what  should  be  the  area 
of  true  bone.  The  same  irregularity  of  line  and  shape  is  ob- 
served in  the  medullary  spaces  of  the  newly  formed  osteoid 
tissue. 

As  a  direct  result  of  the  changes  that  have  been  described, 
the  epiphyseal  junctions  are  enlarged  and  the  shafts  of  the  bones 
are  thickened  by  the  formation  of  osteoid  tissue  beneath  the 
periosteum.  The  indirect  effects  of  the  disease,  and  of  the 
weakness  that  it  causes  are  deformities,  the  nature  of  which  will 
be  indicated  under  the  heading  of  symptoms.  The  stage  of 
weakness  is  followed  by  that  of  repair,  which  sometimes  goes  on 
with  great  rapidity ;  the  softened  bones  become  abnormally  hard, 
"  eburnated,"  and  premature  solidification  at  the  epiphyseal 
junctions  may  be  one  of  the  remote  results  of  the  disease  that 
accounts  in  part  for  the  dwarfing  of  the  stature,  observed  as 
one  of  the  final  results  of  severe  rhachitis. 


CONGENITAL   AND    ACQUIEED   AFFECTIONS.  521 

Symptoms. — As  the  disease  is  the  effect  of  imperfect  assimi- 
lation its  more  pronounced  symptoms  are  preceded  by  those  of 
indigestion,  such  as  flatulence,  constipation,  and  the  like.  Pro- 
fuse perspiration,  especially  about  the  head,  and  restlessness  at 
night  are  common  symptoms.  Teething  is  often  delayed  or  is 
irregular.  The  infant  is  slow  in  its  movements,  and  makes 
little  effort  to  stand  or  to  walk  at  the  usual  time,  and  if  the 
disease  is  active  the  affected  parts  may  be  sensitive  to  pressure. 

Deformities. — One  of  the  earliest  and  most  constant  evidences 
of  rhachitis  is  the  enlargement  about  the  epiphyseal  junctions, 
an  enlargement  caused  in  part  by  the  direct  hypertrophy  and  in 
part  by  pressure  upon  the  softened  tissues.  The  enlargements 
at  the  junctions  of  the  ribs  and  the  costal  cartilages,  the  rha- 
chitic  rosary^  and  at  the  wrists  and  ankles,  double  joints,  are 
almost  invariably  present  in  well-marked  cases.  The  more 
general  distortions  are  in  part  the  effect  of  atmospheric  pressure, 
in  jDart  the  effect  of  the  force  of  gravity  and  habitual  postures, 
and  in  some  instances  muscular  action  or  injury  may  deform  the 
softened  bones.  These  deformities  differ  greatly  according  to 
the  time  of  onset  of  the  disease,  and  with  its  duration  and 
severity.  The  head  may  be  oblong  in  shape,  or  rectangular, 
caput  quadratum,  and  it  sometimes  presents  prominences  in  the 
frontal  and  parietal  regions  due  to  thickening  of  the  bone,  and 
on  the  posterior  asjDect  depressed  and  softened  areas,  craniotahes. 
The  fontanelles  are  abnormally  large,  and  they  may  remain 
open  long  after  the  usual  time  of  closure. 

The  thorax  is  compressed  from  side  to  side,  the  compression 
being  most  marked  in  the  middle  region,  where  the  ribs  have 
the  longest  cartilages  and  the  least  direct  support.  As  secon- 
dary results  the  back  of  the  thorax  is  flattened  and  the  sternum 
is  thrust  forward,  forming  the  pigeon  breast.  The  lower  ribs 
are  everted  to  accommodate  the  distended  abdomen,  potbelly. 
In  well-marked  cases  the  rhachitic  chest  presents  two  distinct 
grooves :  one  transverse  in  the  axillary  line,  Harrison  s  groove, 
and  the  other  passing  upward  by  the  side  of  the  rhachitic  rosary. 
These  deformities  are  in  great  degree  causeel  by  atmospheric 
pressure,  but  they  are  increased  if  the  child  assumes  the  sitting 
posture  habitually.  In  this  attitude  the  body  is  inclined  for- 
ward, the  clavicles  are  distorted,  and  the  spine  is  bent  into  a 
more  or  less  rigid  posterior  curve,  most  marked  in  the  lower 
dorsal  and  lumbar  regions,  the  rhachitic  kyphosis.  Less  often 
there  mav  be  a  lateral  deviation  or  scoliosis. 


522 


OBTHOPEDIC  SUBGEB¥. 


The  arms  may  be  distorted  by  the  efforts  of  the  child  to  sup- 
port the  body  in  the  sitting  posture,  or  by  active  exertion,  as  in 
creeping  (Fig.  340).  Occasionally  the  deformity  may  be 
localized  at  the  elbow,  and  sufficiently  marked  to  merit  the  name 
cubitus  varus  or  valgus,  corresponding  to  genu  valgum  or  varum ; 
or  the  principal  distortion  may  be  a  dorsal  convexity  of  the 
lower  extremity  of  the  radius. 

Fig.  340, 


General  rhachitic  deformities,  sliowing  distortions  of  ttie  arms  and  legs  induced 

by  posture. 


Spindle-shaped  phalanges  are  sometimes  noted  among  the 
early  signs  of  rhachitis  in  young  children.^ 

The  bones  of  the  lower  extremities  are  often  distorted,  pri- 
marily by  the  habitual  postures  assumed  in  sitting  or  creeping, 
and  these  deformities  are  usually  exaggerated  when  the  erect 
attitude  is  assumed.  In  some  instances  it  would  appear  that  the 
femoral  necks  are  twisted  backward  somewhat;  this  distortion 
induced  apparently  by  the  cross-legged  attitude  of  sitting  may 
explain  in  part  the  limitation  of  inward  rotation  that  is  some- 

^Neurath,  Wien  Klin.,  v.  xl.,  N.  1617. 


CONGENITAL    AND    ACQUIRED   AFFECTIONS.  523 

times  observed  in  rhachitic  children.  Depression  of  the  femoral 
neck  (coxa  vara)  may  be  present  also,  although  this  deformity 
does  not,  as  a  rule,  attract  attention  until  a  much  later  period  of 
life.  The  changes  in  the  pelvis  are  of  special  interest  to  the 
obstetrician.  These  are  essentially  an  increase  in  the  sacro- 
vertebral  prominence  due  to  the  forward  and  downward  dis- 
placement of  the  sacrum,  an  abnormal  expansion  of  the  ilia, 
caused  by  pressure  of  the  abdominal  contents,  and,  in  some  in- 
stances, a  decrease  of  the  lateral  diameter,  an  effect  of  the 
pressure  of  the  femora  upon  the  yielding  bone. 

In  the  milder  type  of  rhachitis  in  older  children  who  walk, 
the  deformities  are  often  confined  to  the  trunk  and  lower  ex- 
tremities. In  such  cases,  in  addition  to  the  changes  in  the  bones, 
there  is  usually  a  prominent  abdomen  and  increased  lordosis, 
combined  with  slight  habitual  flexion  at  the  hips  and  knees,  the 
rhachitic  attitude. 

If  the  disease  is  severe  and  general  in  its  manifestations  it 
may  be  accompanied  by  pain,  by  sensitiveness  of  the  affected 
bones,  and  by  such  weakness  of  the  lower  extremities  as  may 
simulate  paralysis,  rhachitic  pseudoparalysis.  It  is  probable, 
however,  that  the  cases  in  which  the  pain  is  extreme,  "  acute 
rhachitis,"  are,  in  reality,  scurvy  or  scurvy  and  rhachitis  com- 
bined, scurvy  rickets  so-called. 

Rhachitis,  as  described,  is  the  type  ordinarily  seen  in  hospital 
practice,  and  its  manifestations  are  unmistakable.  In  its  milder 
form  it  is  not  uncommon  among  the  children  of  the  well-to-do, 
whose  hygienic  surroundings  are  good.  In  such  cases  the  most 
marked  symptom  is  weakness.  The  child  is  often  fat  and  well 
developed,  although,  as  a  rule,  pale.  The  abdomen  is  somewhat 
enlarged  and  slight  j)rominences  at  the  epiphyseal  junctions, 
particularly  at  the  wrists,  may  be  made  out.  The  legs  appear 
small  in  proportion  to  the  body,  and  the  ligaments  are  lax,  so 
that  if  the  child  stands  the  feet  are  flat  and  assume  the  attitude 
of  valgus.  In  this  class,  in  which  the  child  is  said  to  have  weak 
ankles,  knock-knee  is  common. 

The  most  common  symptom  of  rhachitis  of  the  mild  type  is 
the  failure  of  the  child  to  attempt  to  walk  at  the  usual  time, 
about  sixteen  months.  A  child  of  normal  intelligence  who  is 
not  ill  and  who  has  not  suffered  from  exhausting  disease  and 
does  not  walk  at  two  years  of  age  is  probably  rhachitic. 

Prognosis. — The  duration  of  the  jDrogressive  stage  of  rhachitis 
depends,  of  course,  upon  the  age  of  the  patient  and  upon  the 


524  OBTHOPEDIC  SUSGEEY. 

treatment.  In  cases  that  are  untreated  and  in  which  the  pre- 
disjDosing  causes  continue,  the  period  of  repair  niav  be  delayed 
for  several  years  or  longer,  as  shown  by  the  fact  that  the  child 
makes  little  effort  to  stand.  But,  in  most  instances,  the  rhachitic 
child  begins  to  walk  during  the  third  year,  and  at  this  time  the 
deformities  of  the  lower  extremity,  knock-knee,  bow-leg,  ilat- 
foot,  and  the  like  usually  develop  or  become  aggravated,  while 
those  of  the  upper  extremity  may  become  less  noticeable. 

The  deformities  of  rhachitis  tend  to  disappear  or  to  become 
less  marked  with  growth ;  the  concavities  of  the  distorted  shafts 
are  filled  by  accretions  of  periosteal  bone,  which  is  again  ab- 
sorbed from  the  interior  as  the  medullary  canal  straightens 
itself.  The  thickened  diaphyses  and  enlarged  epiphyses  become 
more  symmetrical  under  the  influences  of  rapid  growth  and  in- 
creased functional  activity,  but  traces  of  severe  rhachitis  always 
remain,  and  many  of  the  more  noticeable  and  permanent  dis- 
tortions of  the  trunk  and  of  the  lower  extremities  are  due  to 
this  cause. 

The  prognosis  as  to  the  outgrowth  of  rhachitic  deformities 
depends  upon  the  duration  and  the  severity  of  the  disease  and 
upon  the  function  of  the  deformed  part.  Rhachitic  distortions 
of  the  arms  almost  always  disappear.  The  rhachitic  chest  is 
rarely  seen  in  the  adolescent  or  adult.  The  rhachitic  kyphosis 
is  corrected  or  modified  when  the  erect  posture  is  assumed,  but 
rhachitic  scoliosis,  on  the  other  hand  usually  increases  with  the 
growth.  Distortions  of  the  lower  extremities  may  occasionally 
entirely  disaj^pear,  and  in  most  cases  they  are  less  marked  in 
the  adult  than  in  the  child.  Stunting  of  the  growth  is  a  con- 
stant efi^ect  of  severe  and  prolonged  rhachitis;  it  depends  in  part 
upon  the  arrest  of  development  and  deformity  during  the  active 
stage  of  disease  and  in  part  upon  premature  consolidation  at 
the  epij)hyseal  junctions. 

Treatment. — The  treatment  of  rhachitis  consists  essentially 
in  a  reversal  of  the  conditions  under  which  it  developed.  It  is 
therefore  dietetic,  hygienic,  and  medicinal.  Deformity,  the 
effect  of  the  disease,  may  be  prevented  by  guarding  the  weakened 
bones  from  overstrain,  and  it  may  be  remedied,  if  it  be  present^ 
by  manipulation  or  by  mechanical  or  by  operative  treatment. 

The  more  detailed  treatment  of  rhachitis  may  be  found  in 
works  on  Pediatrics.  In  general,  the  diet  in  the  cases  develop- 
ing in  early  infancy  should  be  of  milk,  especially  modified  ac- 
cording to  the  need  of  the  patient.    At  a  later  time,  correspond- 


CONGENITAL    AND    ACQUIBED   AFFECTIONS.  525 

ing  to  the  normal  period  of  weaning,  the  diet  should  be  largely 
animal,  to  the  exclusion  of  starchy  food,  cream  and  fresh  butter 
being  especially  valuable. 

The  patient,  protected  by  proper  woollen  underclothing,  should 
pass  as  much  time  as  possible  in  the  open  air,  and  should  sleep 
in  a  well-ventilated  room.  Daily  salt  baths  are  recommended 
for  older  chidren,  and  regular  massage  of  the  extremities  and  of 
the  abdomen  should  be  employed.  Medicinal  treatment  is  of 
secondary  importance.  The  bowels  should  be  regulated  and 
digestion  should  be  aided  by  proper  remedies.  For  ansemia, 
which  is  usually  present,  the  syrup  of  the  iodide  of  iron  is  of 
value ;  cod-liver  oil  serves  both  as  a  food  and  medicine,  when  it 
is  readily  assimilated.  It  is  unlikely  that  any  drug  has  a  very 
direct  influence  on  the  disease.  Phosphorus  in  doses  of  2^-^  to 
j^Q-  of  a  grain  is  often  given,  and  is  supposed  to  lessen  the  ab- 
normal congestion  of  the  bones,  while  the  deficiency  of  lime 
salts  may  be  supplied  possibly  by  the  administration  of  lime  in 
some  form,  the  syrup  of  the  lactophosphate  of  lime  being  a 
favorite  prescription. 

The  prevention  of  deformity,  other  than  by  the  means  already 
enumerated,  consists  in  preventing  habitual  postures  that  pre- 
dispose to  deformity,  and  in  daily  massage  and  manipulative 
correction  of  incipient  distortions.  Young  infants  and  those 
whose  bones  are  especially  vulnerable  should  spend  much  of  the 
time  in  the  reclining  posture.  The  stretcher  frame  or  similar 
appliance  is  especially  useful  in  the  treatment  of  this  class  of 
cases.  The  treatment  of  the  more  advanced  deformities,  by 
braces  or  by  operation,  is. described  elsewhere. 

"LATE  RICKETS." 

Late  rickets  is,  as  the  name  implies,  an  affection  presenting 
all  the  characteristics  of  the  common  infantile  form.  This,  in 
rare  instances,  appears  in  later  childhood  or  even  in  adolescence ; 
in  most  instances  the  affection  appears  to  be  a  continuation  or 
recrudescence  of  the  infantile  form ;  in  others  no  history  of  a 
preceding  affection  can  be  obtained.^ 

Adolescence  when  growth  is  rapid  is  a  period  of  instability 
when  static  deformities  develop  or  if  already  present  are  exag- 

^  Drewitt,  Transactions  of  the  London  Pathological  Society,  1881,  vol. 
xxxii.  Glutton,  St.  Thomas'  Hospital  Reports,  1884,  vol.  xiv.  Horvritz, 
Am.  J.  Orthopedic  Surgery,  Nov.,  1909.  Emslie,  St.  Barth.  Hosp.  Reports, 
V.  42,  1906. 


526 


OBTEOPEDIC  SUBGEBY. 


gerated  particularly  in  subjects  living  under  unfavorable  con- 
ditions v^ho  are  overburdened  or  overv^^orked. 

By  many  writers  the  term  late  rickets  is  improperly  used  to 
explain  genu  valgum,  coxa  vara,  and  the  like  in  subjects  of  this 
class  althoiigh  none  of  the  distinctive  sigiis  of  the  disease  are 
present. 

CHONDRODYSTROPHIA. 

Synonym. — Achondroplasia. 

Cases  that  present  the  signs  of  what  appears  to  be  severe 
general  rhachitis  at  birth  are  not  especially  uncommon.  The 
trunk  seems  long  and  the  upper  arms  and  thighs  are  dispro- 

FiG.  341. 


Chondrodystrophia  of  slight  degree,  contrasted  with  ordinary  rhachitis,  in 
sisters.  1.  Chondrodystrophia.  Broad,  short,  very  flexible  hands  ;  trunk  dispro- 
portionately long;  knock-knees.  Age,  five  and  a  half  years;  height,  SQi/o  inches; 
normal  height,  40  inches.  2.  Rhachitis,  bow-legs;  age,  four  years;  height  Si- 
inches  ;  normal  height,  36  inches. 


CONGENITAL   AND    ACQUIRED   AFFECTIONS.  527 

portionally  short  and  distorted,  as  compared  to  leiigtli  of  the 
stunted  limbs.  The  head  is  large.  The  face  is  flattened,  the 
nose  sunken  and  the  skin  may  be  thickened,  the  chest  presents 
a  pigeon-like  distortion,  and  the  extremities  of  the  bones  appear 
to  be  generally  enlarged.  The  hands  and  feet  are  short  and 
broad  and  the  joints  seem  relaxed.  In  some  instances  the  back 
is  curved  into  a  rigid  kyphosis  or  scoliosis,  and  restricted  motion 
or  apparent  fixation  of  many  of  the  joints  may  be  present.^ 

Etiology  and  Pathology. — These  cases  were  formerly  sup- 
posed to  be  instances  of  intrauterine  rhachitis.  Chondrodys- 
trophia  is  not,  however,  the  result  of  a  disturbance  of  nutrition ; 
it  is  due  apparently  to  a  congenital  defect  or  interference  with 
the  development  of  the  cartilaginous  skeleton  beginning  at 
different  periods  of  intrauterine  life,  the  apparent  enlarge- 
ment at  the  joints  being  due  to  formation  of  periosteal  bone  at 
the  diaphyseal  extremities.  Rhachitis  is  characterized  by  thick- 
ening about  the  epiphyseal  cartilages  and  by  delayed  ossifica- 

FiG.  342. 


Cretinism  in  infancy. 

tion.  In  chondrodystrophia,  on  the  contrary,  there  is  atrophy 
of  the  epiphyseal  cartilages.  On  section  of  a  bone  the  shaft  is 
seen  to  be  thickened,  stunted,  and  irregular  in  outline.  The 
epiphyses  are  often  of  normal  size  and  consistency  but  the  con- 
necting cartilage  is  irregular  and  atrophied. 

Chondrodystrophia  is  sometimes  seen  (Fig.  341)  in  a  very 
mild  form;  the  appearance  of  the  child  suggests  rhachitis,  but 
the  stunting  of  the  growth  is  greater  than  is  ever  the  result  of 
rhachitis  of  corresponding  severity. 

Cretinism.- — Cretinism  may  cause  a  similar  dwarfing  of  the 
stature,  and  may  be  combined  with  chondrodystrophia,  but  the 

^  Eoos,  Zeits.  f .  klin.  Med.,  vol.  xlviii.  Schirmer,  Cent,  f .  cl.  Grenzgeb. 
Med.  u.  Chir.,  N.  10,  1907. 


528  OETHOPEDIC  SUSGEEY. 

symptoms  of  mental  deficiency  that  accompany  cretinism  are 
lacking  in  this  affection  (Fig.  342). 

Treatment. — The  treatment  of  chondrodystrophia  consists  in 
regular  massage  and  manipulation  of  the  distorted  parts  and 
of  the  anchylosed  joints.  If  the  deformity  of  the  spine  is  ex- 
treme and  if  the  joints  are  weak,  rest  on  the  stretcher  frame  is 
advisable.  If  congenital  cretinism  is  suspected  the  administra- 
tion of  thyroid  extract  is  indicated. 

Prognosis.- — By  persistent  treatment  the  range  of  motion  in 
the  stiffened  joints  may  be  regained.  The  more  extreme  dis- 
tortions of  the  limbs  disappear  in  the  process  of  development. 
The  patient  is,  however,  dwarfed,  the  average  height  in  adult 
age  according  to  Schirmier  being  from  33  to  53  inches,  the  large 
head  and  the  stunted  extremities  indicating  the  cause. 

INFANTILE  SCORBUTUS. 

Synonyms. — Scurvy,  scurvy  rickets. 

Scurvy  in  infancy,  as  at  other  periods  of  life,  is  a  constitu- 
tional disease  dependent  upon  impaired  nutrition,  caused  ap- 
parently by  unsuitable  food.  The  disease  was  originally  de- 
scribed by  Smith  and  Barlow  as  scurvy  rickets,  but  it  may,  and 
often  does,  occur  independently  of  the  latter  aft"ection. 

Pathology. ^ — The  pathological  changes  most  often  found  in 
cases  of  the  advanced  type  are  hemorrhages  beneath  the  mucous 
membranes  and  the  periosteum.  Separation  of  the  epiphyses 
may  occur  in  extreme  cases. 

Sjmaptoms. — The  disease  is  most  often  seen  in  bottle-fed 
infants  from  six  to  eighteen  months  of  age  of  the  better  class, 
fed  upon  sterilized  milk  or  for  whom  sterilized  milk  has  been 
the  basis  of  the  diet.  In  some  instances  the  patients  are  evi- 
dently ill-nourished,  but  in  others  they  may  aj)pear  to  be  in  good 
condition.  The  early  symptoms  resemble  rheumatism.  The 
child  shows  evidences  of  discomfort  when  certain  joints,  usually 
of  the  lower  extremity,  are  moved,  and  as  the  disease  progresses 
it  may  scream  whenever  it  is  turned  or  lifted.  The  painful 
joints  are  sensitive  to  pressure  and  they  may  be  somewhat  en- 
larged, but  local  heat  and  redness,  as  well  as  fever,  are,  as  a 
rule,  absent.  After  dentition  the  gums  may  be  swollen  and 
spongy,  and  hemorrhages  into  the  skin  or  beneath  the  mucous 
membranes  may  occur.  In  extreme  cases  the  swelling  about  a 
joint  due  to  effusion  of  blood  and  accompanied,  it  may  be,  by 
separation  of  the  epiphyses  may  be  mistaken  for  the  symptoms 
of  infectious  epiphysitis  or  even  for  sarcoma. 


CONGENITAL   AND    ACQUIRED   AFFECTIONS.  529 

Treatment. — The  treatment  consists  primarily  in  the  regula- 
tion of  the  diet,  particularly  in  the  substitution  of  fresh  un- 
cooked milk,  properly  modified,  for  the  patent  food  or  sterilized 
milk  that  may  have  been  employed.  This  should  be  supple- 
mented by  orange-juice  or  that  of  other  fresh  fruit.  The  change 
of  diet  usually  relieves  the  symptoms.  During  the  painful  stage 
of  the  disease  complete  rest  in  the  horizontal  position  on  a  pil- 
low or  frame  may  be  indicated ;  later,  massage  of  the  limbs  and 
back  may  be  of  service  in  improving  the  nutrition  and  remedy- 
ing slight  deformity. 

FRAGILITAS  OSSIUM. 

Synonyms. — Idiopathic  osteopsathyrosis.  Osteogenesis  Im- 
perfecta. 

Idiopathic  fragility  or  osteopsathyrosis  is  of  congenital  origin. 
The  bones,  particularly  those  of  the  lower  extremity,  are  deli- 
cate in  structure  and  usually  short.  The  epiphyseal  cartilages 
appear  to  be  relatively  normal  but  the  periosteal  growth  of  bone 
is  deficient.  The  bone  is  soft,  in  part  cartilaginous,  and  the 
periosteal  tissue  extends  into  its  substance.  In  such  cases  there 
may  be  distortions  at  birth,  apparently  caused  by  intrauterine 
fractures,  and  in  after-life  fracture  may  follow  the  slightest 
accident  or  even  ordinary  movement.  Blanchard^  has  reported 
a  case  in  which  there  were  seventy  distinct  fractures  between 
the  ages  of  twc5  months  and  twenty-seven  years.  A  similar  case 
was  for  many  years  under  treatment  in  the  Hospital  for  Rup- 
tured and  Crippled.  For  a  part  of  the  time  the  trunk  and  legs 
were  enclosed  in  a  plaster-of-Paris  casing  to  prevent  the  frac- 
tures that  followed  even  ordinary  movements.  At  the  age  of 
fourteen  the  strength  of  the  bones  had  increased  sufiiciently  to 
enable  the  patient  to  walk  about  with  the  support  of  braces,  but 
in  stature  he  resembled  a  child  of  seven  years. 

Fractures  in  this  class  of  cases  are  attended  with  but  little 
pain.  They  unite  slowly  with  but  small  callus.  It  is  prac- 
tically impossible  to  prevent  a  certain  amount  of  deformity. 
With  advancing  years  the  liability  to  fracture  may  diminish, 
but,  as  a  rule,  the  patient  is  disabled  and  dwarfed  in  stature. 

The  treatment  is  protective.  Massage,  the  Bier  treatment, 
and  the  like  may  be  of  some  service  in  improving  local  nutri- 
tion.    Medication  is  of  little  avail. ^ 

^  Transactions  American  Orthopedic  Association,  vol.  vi. 

-  Porak,  Bull,  et  Mem.  de  la  Soc.  Obst.  et  Gyn.  de  Paris,  1840.     Salvetti, 
Beitr.  zur  path.  Anat.  und  allg.  Path.,  1894,  Bd.  xvi.     Nathan,  Amer.  Jour. 
Med.  Sci.,  February,  1905. 
34 


530  OBIEOPEDIC  SUEGEEY. 

There  are  many  other  conditions  that  cause  local  or  general 
fragility"  of  the  bones  and  thus  an  increased  liability  to  fracture. 
Among  the  local  causes  are  tumors,  cysts,  inflammatory  proc- 
esses, syphilis,  and  the  like.  The  general  conditions  would  in- 
clude the  weakness  of  old  age,  sometimes  called  senile  rickets; 
the  atrophy  caused  by  disuse  incidental  to  chronic  joint  disease, 
or  the  ,weakness  that  may  be  caused  by  certain  diseases  of  the 
nervous  system.  In  other  instances  the  weakening  may  be  the 
direct  result  of  disease,  as,  for  example,  osteomalacia  or  rha- 
chitis. 

OSTEOMALACIA. 

Synonym- — Mollites  ossium. 

Osteomalacia  is  a  disease  of  an  inflammatory  nature,  charac- 
terized by  an  absorption  of  the  earthy  substances  (decalcifica- 
tion) of  the  bones  and  by  deformity.  The  disease  is  particularly 
one  of  adult  life.  It  is  far  more  common  among  females  than 
males,  and  pregnancy,  in  about  half  of  the  cases  that  have  been 
reported,  seemed  to  be  the  exciting  cause.  The  disease  usually 
begins  insidiously.  The  symptoms  are  pain  on  motion,  referred 
to  the  pelvis  and  to  the  thighs.  This  is  supposed  to  be  of  rheu- 
matic origin  until  the  character  of  the  affection  is  made  evident 
by  the  weakness  of  the  limbs  and  by  the  deformities.  These 
deformities  are  of  greater  interest  to  the  obstetrician  than  to  the 
surgeon,  for  when  the  affection  complicates  pregnancy  the  dis- 
tortion of  the  pelvis  may  be  so  great  as  to  prevent  normal  de- 
livery. 

Osteomalacia  in  Childhood. — Three  cases  of  osteomalacia  in 
childhood  have  been  reported  by  Siegert,^  and  one  case  has  come 
under  my  observation.  The  patient,  one  of  twelve  living  chil- 
dren of  healthy  parents,  was  nursed  by  his  mother  for  the  usual 
period,  and  until  the  age  of  four  years  he  appeared  to  be  per- 
fectly healthy.  At  this  time,  without  known  cause,  general  weak- 
ness became  apparent,  and  at  the  same  time  deformities  of  the 
lower  extremities  developed.  At  the  age  of  six  years  he  was  unable 
to  stand.  The  condition  of  the  patient  at  nine  years  of  age  is 
shown  in  Fig.  343.  The  patient  had  never  suffered  from  pain 
or  discomfort.  The  lower  extremities  were  somewhat  atrophied 
from  disuse,  the  bones  were  abnormally  flexible  and  were  dis- 
torted to  a  moderate  degree.  The  epiphyses  were  not  enlarged. 
^  Miinch.  med.  Woclieuschr.,  November  1,  1898. 


CONGENITAL    AND   ACQUIBED   AFFECTIONS.  531 

Treatment. — As  the  etiology  of  the  affection  is  unknown,  the 
treatment  is  therefore  experimental  or  symptomatic  and  pallia- 
tive. 

Fig.  343. 


Osteomalacia  in  a  child. 

Local  Osteomalacia. — When  deformity  of  a  bone  appears  and 
increases  without  apparent  cause  it  is  often  assumed  that  a  local 
disease — "  local  rickets  or  local  osteomalacia  " — is  present. 

Local  weakness  and  deformity  may  be  caused  by  injury  or  by 
subacute  osteomyelitis  and  the  like.  If  there  is  a  distinct  local 
disease  that  deserves  the  name  of  local  osteomalacia  its  cause 
has  not  been  determined. 

OSTEITIS  DEFORMANS. 

This  disease  was  first  described  by  Paget^  in  1877.  It  is  a 
chronic  inflammatory  affection  of  the  bones,  characterized  by 
hypertrophy  and  softening.  "  The  bones  enlarge,  soften,  and 
those  bearing  weight  become  unnaturally  curved  and  mis- 
shapen." 

^  Med.  Chir.  Trans.,  Vols.  xl.  and  Ixv. 


532 


OBTHOPEDIC  SUSGEBY. 


Section  of  an  affected  bone  shows  it  to  be  markedly  increased 
in  size,  and  somewhat  in  length,  by  a  combination  of  rarefying 
and  formative  osteitis.  The  inner  layers  become  porous,  and  at 
the  same  time  new  bone  is  deposited  beneath  the  periosteum. 

The  disease  appears  to  be  confined  to  adult  life,  and  it  is 
apparently  more  common  among  males  than  females.  Of  67 
cases  collected  by  Packard,  Steele,  and  Kirkbride,-^  61  per  cent. 

Fig.  34i. 


Osteitis  deformans  in  a  female  seventy-three  years  of  age.      (Lunn.=) 


As  a  rule,  the  lesions  are  symmetrical  and  general  in  dis- 
tribution, the  bones  of  the  lower  extremity,  the  skull,  and  the 
spine  being  more  often  involved.  Thus  the  head  progressively 
increases  in  size,  and  the  legs  become  bowed.  If  the  spine  is 
affected  it  bends  forward,  forming  a  long,  more  or  less  rigid 
kyjDhosis. 

Aside  from  the  deformities  and  the  characteristic  enlarge- 
ment of  the  bones,  the  symptoms  are  not  marked.  At  times  com- 
plaint is  made  of  pain  usually  supposed  to  be  rheumatic  until 
the  characteristic  changes  in  the  bones  appear.  The  disease  is 
extremely  chronic  in  its  course,  and,  as  a  rule,  the  general 
health  is  not  seriously  affected.  In  several  instances  sarcoma 
of  bone  finally  caused  death  many  years  after  the  onset  of  the 
disease.    Its  etiology  is  unknown,  and  its  treatment  is  palliative. 

Local  Osteitis  Deformans. — ^A  disease  resembling  in  its  gen- 
eral characteristics  osteitis  deformans  may  ajjpear  in  a  single 
bone  or  in  corresponding  bones  of  the  lower  extremity  (Fig. 
347).  It  may  persist  indefinitely,  with  but  little  tendency 
toward  the  general  involvement  of  the  l)ones  characteristic  of 
Paget's  disease,  whether  it  is  a  varietv  of  osteitis  deformans  or 
were  in  males. 

^  American  Journal  of  the  Medical  Sciences,  Xovember,  1901. 

"  Prince,  American  Journal  of  the  Medical  Sciences,  November,  1902. 


CONGENITAL  AND  ACQUIRED  AFFECTIONS. 


533 


is  of  another  class  is  not  apparent  at  present.  The  treatment  is 
symptomatic,  being  directed  especially  toward  relief  of  strain 
that  induces  discomfort  and  increases  the  deformity. 


Fig.  345. 


Fig.  346. 


Normal  tibia  and  foot. 


Osteitis  deformans.  Hyperostosis 
and  decalcification.  (Pitz.)  Con 
trast  with  Fig.  345. 


SECONDARY  HYPERTROPHIC  OSTEOARTHROPATHY.^ 

Osteoarthropathy  is  an  inflammatory  disease  of  the  bone  char- 
acterized by  hypertrophy,  clubbing:  of  the  fingers,  and  effusion 
into  certain  of  the  joints.  The  hypertrophy  is  caused  by  a  de- 
position of  layers. of  bone  beneath  the  periosteum  of  the  meta- 
carpal and  metatarsal  bones,  the  phalanges  and  the  distal  ex- 
tremities of  the  adjoining  bones  of  the  arms  and  legs.  Less 
often  the  area  of  the  disease  is  more  extensive,  involving  the 
femora,  the  humeri,  and  the  sjDine  even. 

Osteoarthropathy  is  usually  a  complication  of  pre-existing" 

chronic  disease,  v^^hich  causes  interference  with  the  circulation 

and  which  is  accompanied  by  suppuration.     Thus  it  is  most 

often  found  in  combination  with  disease  of  the  lungs.     The 

^  Marie,  Eevue  M&dicale,  Paris,  1890,  x.,  p.  1.  Bambtirger,  Wiener  klin. 
Woch.,  1889,  No.  11;  Deutsche  Chir.,  1899,  L.  28.  Alexander,  St.  Barth. 
Hosp.  Eeports,  42,  1906. 


534 


OBTHOPEDIC  SURGERY. 


Fig.  347. 


clubbing  of  the  terminal  phalanges  and  hypertrophy  of  the 
finger-nails  first  appear,  later  an  increasing  enlargement  of  the 
wrists  and  ankles,  and  of  the  hands  and  feet,  accompanied  by 

discomfort,  sensitiveness  to  pres- 
sure, and  often  by  effusion  into 
the  neighboring  joints,  symptoms 
that  T^ould  be  classed  as  rheumatic 
were  it  not  for  the  evident  hyper- 
trophy. 

The  clubbing  of  the  fingers  is 
due,  in  part  at  least,  to  impair- 
ment of  the  circulation,  and  the 
connection  of  the  disease  of  the 
bones  with  that  of  the  lungs  has 
suggested  the  theory  that  it  is 
caused  by  the  absorption  of  toxins, 
and  that  its  etiology  is  similar  to 
the  amyloid  hypertrophy  of  the 
internal  organs  that  sometimes 
follows  chronic  disease  of  bones 
and  joints  attended  by  suppura- 
tion. The  treatment  is  sympto- 
matic, and  as  the  affection  is  al- 
most always  secondary  to  graver 
disease,  but  little  is  known  of  its 
outcome.  It  is  certain,  however, 
that  the  secondary  osteoarthro- 
pathic  symptoms  become  less 
marked  or  may  even  disappear  as 
the  patient  recovers  from  the  orig- 
inal disease  of  the  lungs  or  other 
organs.  The  affection  is  very  un- 
common in  childhood.  In  one 
characteristic  case  observed  by  the 
writer  complete  recovery  followed 
the  cure  of  Pott's  disease  and  chronic  bronchitis,  the  hyper- 
trophied  phalanges  alone  remaining.^ 


PH^^H 

i^'-'.^^^^Hi 

M^^^^^^^^^H 

WW 

W  \ 

H^^^^l 

Ifl 

j\ 

*^ 

Osteitis  deformans  of  both  fe- 
mora most  marked  on  the  right 
side  Duration  of  symptoms  3 
years.  Symptoms  increasing  out- 
ward bowing  of  the  limbs,  also 
pain  and  weakness  after  over- 
exertion. 


ACROMEGALY. 

This  affection  is  also  characterized  by  progressive  enlarge- 
ment of  the  hands  and  feet,  but  it  differs  from  osteoarthropathy 

^Whitman,  Pediatrics,  February  1.5,  1899;  Gushing,  J.  Am.  Med.  Assn., 
July  24,  1909. 


CONGENITAL  AND  ACQUIEED  AFFECTIONS.  535 

in  that  all  the  tissues  are  hypertrojohied.  The  hypertrophy  of 
the  bone  is  limited  to  the  extremities,  and  is  slight  compared 
with  that  of  the  soft  parts.  The  face  is  often  involved,  the 
tissues  of  the  nose,  lips,  and  ears  being  enlarged  and  thickened, 
together  v^ith  the  underlying  bones,  so  that  the  expression  is 
markedly  changed.  The  affection  most  often  appears  or  attracts 
attention  in  early  adult  life.  It  is  usually  slowly  progressive 
and  it  may  be  accompanied  by  mental  impairment. 

Acromegaly  is  common  among  those  of  gigantic  stature,  the 
local  hypertrophy  and  the  gigantism  both  being  due,  it  is  sup- 
posed, to  disease  and  increased  secretion  of  the  pituitary  gland. 

"  Two  conditions,  one  due  to  a  pathologically  increased  activity 
of  the  pars  anterior  of  the  hypophysis  (hyperpituitarism),  the 
other  to  a  diminished  activity  of  the  same  epithelial  structure 
(hypopituitarism),  seem  capable  of  clinical  differentiation. 

The  former  expresses  itself  chiefly  as  a  process  of  overgrowth 
- — gigantism,  when  originating  in  youth,  acromegaly  when 
originating  in  adult  life.  The  latter  expresses  itself  chiefly  as 
an  excessive,  often  a  rapid,  deposition  of  fat  with  persistence  of 
infantile  sexual  characteristics  when  the  process  dates  from 
youth,  and  a  tendency  toward  a  loss  of  the  acquired  signs  of 
adolescence  when  it  first  appears  in  adult  life"  (Gushing). 


CHAPTEK    XV. 


CONGENITAL  DISLOCATION  OF  THE  HIP  AND  COXA  VARA. 

CONGENITAL  DISLOCATION  AT  THE  HIP-JOINT. 

Of  all  the  congenital  dislocations,  or,  perhaps,  more  properly, 
misplacements,  that  of  the  hip-joint  is  by  far  the  most  common 
and  the  most  important. 

Statistics.— Congenital  dislocation  of  the  hip  is  much  more 
common  in  females  than  in  males.    In  1362  cases  collected  from 

Fig.  348. 


Congenital  dislocation  of  the  hip,  showing  the  elongated  capsule  and  the  right- 
angled  relation  of  the  neck  to  the  shaft  of  the  femur.      (William  Adams.) 

different  sources  by  Hoffa,  1189  (87.3  per  cent.)  were  in  fe- 
males and  173  (12.7  per  cent.)  in  males.  Of  1039  cases  seen  at 
the  Polyclinic  in  Milan,  867  (83.4  per  cent.)  were  in  females, 
172  (16.6  per  cent.)  in  males. ^     In  801  cases  from  the  records 

^  Bernacchi,  Zeits.  Ortli.  Chir.,  vol.  ii.,  p.  275.  For  complete  review  of 
tlie  literature  see  Schultze,  Arch.  f.  Mechanotherapie  u.  unfall.  Chir.,  7,  1, 
1908. 

536 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     537 

of  the  Hospital  for  Ruptured  stnd  Crippled,   655    (81.6  per 
cent.)  were  in  females  and  146  (18.3  per  cent.)  in  males. 

The  dislocation  is  more  often  unilateral  than  bilateral.  In 
Hoffa's  series  of  1362  cases  860  (63.1  per  cent.)  were  single; 
392  of  the  right,  468  of  the  left  side.  In  502  cases  (36.9  per 
cent.)  the  displacement  was  bilateral. 

Statistics  of  801  Cases  of  Congenital  Dislocation  of  Hip,  Recorded  at 
THE  Hospital  for  Ruptured  and  Crippled. 

Per  Cent. 

Males    , 146  18.35 

Females    ' 655  81.65 

801  100.00 

Right  hip   206  26.07 

Left    hip    353  44.69 

Both    231  29.24 

790     ^         100.00 
Not    specified    11 

801 

Males. 

Right    hip    43  30.49 

Left    hip    55  39.02 

Both    4Z  30.49 

141  lOCKOO 

Not    specified    5 

146 

FeTnales. 

Right  hip   163  25.10 

Left  hip   298  45.94 

Both    188  28.96 

649  100.00 

Not  specified   6 

655 

The  dislocation  at  the  time  when  the  patients  are  brought  for 
treatment  is  usually  posterior,  upon  the  dorsum  of  the  ilium; 
in  other  instances  it  is  anterior,  and  the  head  of  the  bone  may 
be  felt  beneath  the  anterior  superior  spine.  It  is  probable,  how- 
ever, that  the  primary  displacement  is  often  directly  upward, 
for  in  those  cases  discovered  in  infancy  this  position  is  common. 

Pathology. — The  pathological  anatomy  of  the  dislocation  was 
first  clearly  demonstrated  by  Dupuytren  in  1826,  and  since 
1890,  when  the  open  operation  was  first  performed,  the  exact 
relation  and  the  appearances  of  the  different  components  of 
the  joint  have  been  described  in  detail  by  IToffa,  Lorenz,  and 
other  operators. 

The  condition  of  the  joint  varies  with  the  age  of  the  patient 


538 


OETHOPEDIC  SURGE EY. 


Fig.  349. 


and  the  strain  and  friction  to  which  the  displaced  parts  have 
been  subjected.  In  early  infancy  it  may  be  assumed  that  the 
head  of  the  bone  lies  in  close  proximity  to  what  is,  in  some  in- 
stances, a  practically  normal  acetabulum;  in  others  to  one  that 
is  somewhat  rudimentary,  often  shallow  and  small,  sometimes 
of  an  oval  or  of  a  somewhat  triangular  shape.  The  acetabulum 
is  covered  with  normal  hyaline  cartilage,  the  ligamentum  teres 
is  present,  and  the  capsule  is  of  nearly  normal  structure.  At  a 
later  time,  when  the  joint  is  exposed  at  operation  at  the  age  of 
five  or  more  years,  the  capacity  of  the  rudimentary  acetabulum 

may  be  lessened  by  a  de- 
posit of  fat  and  fibrous 
tissue.  As  a  rule,  how- 
ever, it  appears  to  be  of 
fair  size  and  depth.  The 
capsule  is  elongated  to  ac- 
commodate the  upward 
displacement  of  the  fe- 
mur. It  is  hypertrophied, 
especially  where  it  covers 
the  upper  part  of  the  head 
of  the  bone,  and  it  may  be 
drawn  into  shape  like  an 
hour-glass;  the  upper  part 
contains  the  head  of  the 
femur;  the  anterior  wall 
is  drawn  tightly  across  the 
acetabulum,  forming  at 
its  upper  border  a  narrow 
slit-like  communication, 
through  which  the  liga- 
mentum teres  passes  if  it 
be  present  (Fig.  349).  The  interior  of  the  capsule  is  in  part 
lined  with  synovial  membrane,  and  it  often  contains  more 
synovial  fluid  than  is  found  in  the  normal  joint. 

The  ligamentum  teres,  although  probably  present  at  birth  in 
a  large  proportion  of  the  cases,  becomes  attenuated  and  ribbon- 
like with  the  increasing  elongation  of  the  capsule,  and  after  the 
age  of  five  years,  or  at  the  time  when  the  open  operation  is  per- 
formed, it  is  usually  absent,  and  far  more  often  in  the  bilateral 
than  in  unilateral  cases.  According  to  Lorenz,  in  52  cases  be- 
tween two  and  a  half  and  five  years  it  was  present  in  17;  in  48 


Congenital  dislocation  of  the  hip,  show- 
ing the  original  and  the  acquired  acetabula. 
(Lorenz.) 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VABA.     539 

cases  beyond  the  age  of  five  years  it  was  present  in  but  4.  In 
rare  instances  it  may  be  bypertrojDhied.  In  my  own  experience 
tbe  ligament  is  present  in  a  very  much  larger  proportion  of  the 
cases,  although  it  is  often  so  rudimentary  that  it  might  easily 
be  overlooked. 

A  shallow  secondary  acetabulum,  formed  in  part  by  the  direct 
pressure  of  the  head  of  the  bone  through  the  adherent  capsule, 
and  in  part  the  result  of  irritation  of  the  periosteum,  is  usually 
found  upon  the  ilium  (Fig.  350),  but  it  is  not  often  of  sufficient 

Fig.  350. 


\       > 


Congenital  dislocation  of  the  hip  in  adult  age,  showing  the  abnormal  shape 
of  the  acetabulum,  the  depressions  in  the  ilium  caused  by  the  pressure  and  fric- 
tion of  the  head  of  the  femur,  and  the  destructive  effect  of  this  pressure  and 
friction  upon  the  femur.      (Adams.) 


depth  to  assure  a  secure  support  for  the  head  of  the  femur ;  thus 
its  upper  margin  gradually  recedes  or  two  distinct  depressions 
may  be  formed,  one  above  the  other.  The  upper  extremity  of 
the  femur  is  usually  somewhat  atrophied.  The  neck  is  often 
shorter  than  normal,  and  its  angle  may  be  lessened,  or  occasion- 
ally increased,  and  in  many  instances  its  forward  inclination 
is  increased,  usually  by  anterior  torsion  of  the  shaft.     The  head 


540 


OBTHOPEDIC  SUBGEEY. 


of  the  femur  may  be  nearly  normal,  although  usually  it  is  some- 
what flattened  on  its  posterior  and  under  surface,  or  it  may  be 
somewhat  conical,  acorn-like  in  shape,  or  again  compressed  from, 
side  to  side  to  an  almond  shape  or  otherwise  distorted. 

There  are  secondary  changes  in  the  bones  of  the  pelvis.     In 
unilateral  dislocation  the  pehds  is  usually  somewhat  atrophied 


Fig.  351. 


Fig.  352. 


Unilateral  dislocation,  showing  the 
inclination  of  the  body  toward  the 
shorter  limb. 


The  same  patient  before  operation, 
showing  the  abnormal  lordosis  and  rota- 
tion of  the  pelvis.  iSee  Figs.  379  and 
380). 


on  the  affected  side,  and  a  lateral  inclination  of  the  spine  may 
be  present.  The  final  changes  in  the  pelvis  caused  by  the  bi- 
lateral dislocation  are  more  important ;  its  inclination  is  in- 
creased, the  lumbar  lordosis  is  exaggerated,  the  sacrum  is  forced 
forward  and  downward  so  that  the  anteroposterior  diameter  is 
diminished:  the  tuberosities  of  the  ischia  are  everted  and  the 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VAEA.     54  J 

■transverse  diameter  of  both  the  inlet  and  outlet  of  the  pelvis  is 
increased. 

The  long  muscles  of  fhe  thigh  are  shortened,  while  those  at- 
tached to  the  pelvis  and  trochanter  are  changed  in  direction  and 
are  usually  lengthened.  There  is  also  a  slight  general  muscular 
atrophy  that  is  particularly  marked  in  the  gluteal  group. 

The  changes  that  have  been  described  are  in  part  congenital, 
in  part  accommodative,  and  in  part  due  to  the  influences  of 
attrition  and  injury,  to  which  the  abnormal  mobility  predis- 
poses. Thus,  as  a  rule,  they  become  more  marked  with  increas- 
ing age,  and  in  some  of  the  adult  specimens  but  little  resem- 
Mance  to  the  normal  parts  remains  (Fig.  350). 

As  a  rule,  congenital  dislocation  of  the  hip  is  not  accom- 
panied by  defective  development  or  deformity  elsewhere,  al- 
though cases  are  sometimes  seen  in  which  a  general  laxity  of 
ligaments  is  present  or  in  which  the  dislocation  may  be  one  of  a 
series  of  deformities  and  malformations. 

Etiology. — In  a  small  proj)ortion  of  the  unilateral  cases  the 
dislocation  may  be  due  to  violence  at  birth,  but  the  fact  that 
nearly  85  per  cent,  of  the  j^atients  are  females  makes  it  evident 
that  the  primary  cause  can-be  neither  injury  nor  disease. 

Hereditary  influence  can  be  established  in  a  few  instances. 
The  writer  has  examined  fhree  female  children  in  a  family  of 
nine,  in  each  of  whom  there  was  dislocation  of  the  left  hip,  the 
■order  being  the  third,  eighth,  and  ninth  child.  Also  twins  in 
another  family,  one  with  single  and  the  other  with  double  dis- 
location. And  in  four  instances  congenital  displacement  was 
present  in  the  mother  of  the  patients.  Vogel,-*^  from  an  investi- 
gation of  200  cases,  concludes  that  heredity  might  have  had 
some  remote  influence  in  30  per  cent. — viz. :  In  6  instances  the 
mother  had  congenital  dislocation,  in  9,  the  father,  in  7  sisters 
of  the  father,  in  8  sisters  of  the  mother,  in  one,  both  father  and 
mother.  In  25  per  cent,  of  the  cases  there  had  been  breech 
presentation. 

Of  the  various  theories  that  have  been  advanced  to  account 
for  the  condition,  the  most  reasonable  seems  to  be  a  predispos- 
ing attitude  of  flexion  and  adduction  of  the  thigh  abnormally 
prolonged.  Dislocation  at  this  joint  is  relatively  frequent  be- 
cause the  acetabulum  is  shallow  in  foetal  life.  According  to 
Sainton's  observations,  in  newborn  children  it  covers  but  one- 
third  of  the  femur,  but  at  the  age  of  five  years  it  is  sufficiently 
deep  to  contain  one-half  of  it. 

^  Deutsch.  Zeits.  f.  Chir.,  71.,  Bd.  iii.  and  iv. 


542 


OSTEOPEDIC  SUPiGEEY. 


Hensner  and  Marcwald/  from  an  examination  of  eighty-five 
foetuses,  conclude  that  the  greater  liahilitv  of  females  to  the  dis- 
location is  explained  by  the  disproportionate  laxity  of  the  capsule 

as  compared  with  males. 
^'^-  ^•^^-  It  is  probable  that  the 

dislocation,  in  some  cases 
at  least,  is  at  birth  a  sub- 
luxation only,  that  be- 
comes complete  through 
muscular  action  and  by 
the  use  o  f  the  limb  in 
standing  and  walking. 

Symptoms. — The  dis- 
placement does  not,  as  a 
rule,  attract  attention  un- 
til the  child  begins  to 
walk,  although  in  some 
cases  the  mother  may  have 
noticed  a  peculiar  breadth 
of  pelvis,  or  a  "  lump  "  on 
the  buttock,  or  a  "  snap- 
ping" about  the  hip-joint, 
or  a  peculiar  attitude  of 
the  limb  before  this  time. 
Unilateral  Dislocation — 
If  the  displacement  is  of 
one  side,  a  limp  is  imme- 
diately apparent,  which 
becomes  more  noticeable 
as  the  child  gTows   older. 

Congenital  dislocation  of  both  hips,  illus-  The  limp  is  peculiar,  and 
trating  the  separation  of  the  thighs,  the  j-j-g  diaracter  is  explained 
abnormal     breadth     of    the     pelvic     region,  .  pit 

and  the  prominent  trochanters.  by  itS  CaUSC  ;  lor  the  short- 

ened limb,  owing  to  the 
elasticity  of  the  capsule,  becomes  still  shorter  when  the  weight 
falls  wpon  it ;  thus  in  walking  there  is  a  peculiar  lunge  of  the 
body  toward  the  short  side,  that  has  been  likened  to  the  motion 
in  walking  down  stairs.  In  the  ordinary  form,  the  head  of 
the  femur  is  displaced  upward  and  backward,  and  in  com- 
pensation the  pelvis  is  tilted  toward  the  short  limb  and  its  in- 
clination is  increased ;  it  is  thus  twisted  downward  and  forward 

'Zeits.  f.  Orth.  Chir.,  1902.  Bd.  x.,  H.  4. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VABA.     543 

SO  that  the  anterior  superior  sj^ine  lies  at  a  lower  level  and  in 
advance  of  that  of  the  opposite  side  (Figs.  351  and  352). 

At  an  early  age  the  shortening  of  the  limb,  due  to  the  eleva- 
tion of  the  trochanter,  is  from  one-half  to  three-quarters  of  an 
inch.  In  later  childhood  the  elevation  is  from  one  and  one-half 
to  two  inches,  anddn  adult  life  it  may  be  considerably  more. 

Fig.  354. 


Bilateral  congenital  dislocation  of  the  hip,  showing  the  exaggerated  lordosis. 


The  effect  of  the  displacement  is  also  shown  by  a  flattening  of 
the  huttock,  and  usually  the  elevated  and  prominent  trochanter 
may  be  seen  as  an  abnormal  lateral  projection,  on  a  level  with 
the  anterior  superior  spine,  which  is,  as  has  been  stated,  some- 
what tilted  downward. 


544  OETHOPEDIC  SUEGEBY. 

In  infancy  motion  in  the  false  joint  is  more  free  than  normal, 
and  the  abnormal  mobility  can  be  demonstrated  by  alternate 
traction  and  npward  pressure  on  the  limb,  but  as  the  femur  be- 
comes larger  and  the  upward  displacement  increases  the  mo- 
bility is  restricted.  The  range  of  abduction  is  much  diminished, 
and  in  extreme  cases  the  limb  may  become  permanently  ad- 
ducted  and  flexed,  thus  adding  the  apparent  shortening  of  ad- 
duction to  that  caused  by  the  dislocation  (Fig.  355). 

Bilateral  Dislocation^ — In  bilateral  dislocation  the  shortening 
of  the  limbs  is,  as  a  rule,  equal  or  nearly  so,  and  if,  as  is  usual, 
both  femora  are  displaced  backward,  the  pelvis  is  tilted  for- 
ward; thus  in  compensation  "the  hollow"  of  the  back  is  in- 
creased, the  abdomen  protrudes,  the  buttocks  are  flattened,  the 

I     Fig.  355. 


Congenital  dislocation  in  an  adolescent,  illustrating  the  -flexion  contraction  in  a 

well-marked  case. 

pelvis  appears  to  be  abnormally  wide,  and  the  thighs  are  sepa-' 
rated  by  a  considerable  interval  (Figs.  353  and  354).     The  limp 
characteristic  of  the  single  displacement  is  replaced  by  an  exag- 
gerated ivaddle,  a  "  sailor  gait." 

General  Symptoms. — In  early  childhood  there  are  no  special 
symptoms  other  than  the  limp  or  the  waddle,  but  as  the  child 
becomes  more  active  it  often  complains  of  discomfort  after 
exertion.  It  is  easily  fatigued,  and  at  times  it  may  suffer  actual 
pain.  These  symptoms  are,  of  course,  more  marked  in  the 
double  than  in  the  single  displacement,  because  in  the  latter 
case  the  normal  limb  is  capable  of  bearing  more  than  its  share 
of  the  strain.  The  symptoms  often  increase  during  adolescence, 
but  they  may  become  less  troublesome  in  adult  life,  when  the 
head  of  the  bone  may  have  found  a  permanent  resting  place  on 


CONGENITAL  DISLOCATION  OF  BIT  AND  COXA  VABA.     545 


Fig.  356. 


tlie  pelvis ;  a  security  which  is  often  assured  hj  a  corresponding- 
limitation  of  the  range  of  motion.  The  shortening  and  the 
secondary  effects  of  the  displacement,  of  course,  persist,  so  that 
the  individual  is,  as  compared  with  the  normal  standard,  more 
or  less  disabled  and  in  certain  instances  noticeably  deformed. 

The  great  majority  of  the  patients  are 
females,  and,  because  of  the  less  laborious 
occupations  and  the  distinctive  dress,  the 
disability  and  its  effects  are  less  serious 
than  if  the  displacement  were  more 
equally  divided  between  the  sexes. 

Anterior  Dislocation. — The  symptoms  of 
the  unilateral  anterior  dislocation,  in 
which  the  head  of  the  bone  lies  beneath  the 
anterior  superior  spine,  are  much  less 
marked  than  in  the  ordinary  form  because 
the  relation  of  the  pelvis  to  the  femur  is 
more  nearly  normal.  The  shortening  is 
less  and  the  limp  is  less  noticeable  because 
the  resistance  of  the  tissues  attached  to  the 
anterior  superior  spine  is  sufficient  to 
assure  a  relatively  secure  support. 

In  bilateral  anterior  dislocation  the 
entire  body  is  swayed  slightly  backward, 
but  the  lumbar  lordosis  is  not  increased ; 
in  fact,  the  back  is  often  peculiarly  flat. 
Otherwise  the  symptoms  do  not  differ, 
except  in  degree,  from  those  of  the  pos- 
terior displacement  (Fig.  356). 

Supracotyloid  Displacement. — As  has  been 
stated,  in  early  cases  the  displacement  may 
be  a  form  of  subluxation  in  which  the  head 
lies  but  slightly  above  the  normal  position. 
The  same  upward  displacement  is  occa- 
sionally found  in  older  subjects.  The 
physical  signs  are  similar  to  those  of  the 
anterior  displacement. 

Diagnosis. — The  diagnosis  offers  no  difficulty.  The  history 
of  the  limp  or  waddle  noticed  when  the  child  began  to  walk  and 
yet  unaccompanied  by  pain  or  preceded  by  injury  or  disease  is 
in  itself  sufficiently  distinctive.  If  the  displacement  is  of  one 
side,  measurement  demonstrates  the  shortening  as  compared 
35 


Bilateral  anterioi-  con- 
genital dislocation.  Tlie 
lordosis  is  far  less 
marked  than  in  the  or- 
dinary form. 


546 


ORTHOPEDIC  SUHGEFY. 


with  the  other  limb,  a  shortening  that  is  explained  bj  the 
prominence  of  the  trochanter  and  its  elevation  above  ISTelaton's 
line.  Traction  or  upward  pressure  on  the  limb  will  demonstrate 
the  abnormal  mobility  of  the  displaced  head ;  and  finally,  if  the 
thigh  be  flexed  and  adducted  to  its  extreme  limit,  the  neck  and 
head  of  the  femur  can  be  easily  distinguished  moving  under  the 
gluteal  muscles  when  the  limb  is  rotated.  Thus  it  may  be 
differentiated  from  depression  of  the  neck  of  the  femur   (coxa 

Fig.  357. 


Bilateral  congenital  dislocation  of  the  liip. 

vara),  in  which,  although  the  trochanter  is  elevated,  the  neck 
and  head  of  the  bone  cannot  be  felt,  and  in  which  the  abnormal 
mobility,  characteristic  of  the  dislocation,  is  absent.  Again, 
coxa  vara  is  almost  never  a  congenital  affection;  therefore,  the 
history  itself  would  practically  exclude  it. 

Upward  disiDlacement  of  the  femur  not  infrequently  follows 
infectious  epipliysiiis  or  arthritis  of  infancy  or  early  childhood. 
In  such  cases  a  part  of  the  upper  extremity  of  the  bone  is 
usually  destroyed,  so  that  the  head  cannot  be  distinguished  on 
palpation.     Although  the  other  physical  signs  are  similar  to 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     547 


Fig.  358. 


those  of  the  congenital  displacement,  the  scars  about  the  joint 
present  the  evidence  of  former  disease,  and  the  history  is  almost 
always  available  for  diagnosis.  Thus,  as  a  rule,  such  disabili- 
ties, as  well  as  traumatic  dislo- 
cations or  other  results  of  in- 
jury or  disease,  are  readily  ex- 
cluded. 

The  bilateral  dislocation  pre- 
sents, of  course,  the  same  phys- 
ical signs  as  the  single  form ;  it 
is  even  more  easily  recognized 
by  the  peculiar  appearance  and 
distinctive  gait  of  the  patient. 
The  waddling  gait  may  be  sim- 
ulated by  that  of  extreme  hoiu- 
legs,  but  the  hip-joints  are,  in 
this  deformity,  normal  in  ap- 
pearance and  function.  The 
swagger  of  lumbar  Pott's  disease 
is  also  somewhat  similar,  but 
this  is  an  acquired  painful  dis- 
ease of  the  spine,  in  which  the 
hip- joints  are  normial  in  appear- 
ance and  usually  so  in  function. 

P seudoliypertrophic  paralysis 
may  be  mentioned  as  causing  a 
somewhat  similar  gait  and  at- 
titude, but  here  the  resemblance 
ceases. 

As  has  been  stated,  the  diag- 
nosis of  congenital  dislocation 
can  be  easily  made  by  physical 
examination ;  the  only  real  diffi- 
culty is  experienced  in  certain  dislocations  or  subluxations  of 
the  anterior  type  and  in  cases  seen  in  early  infancy  in  which 
the  dislocation  may  be  incomplete,  but  opportunity  for  such 
early  diagnosis  is  rarely  offered.  In  doubtful  cases  a  Roentgen 
picture  will  demonstrate  the  character  of  the  disability  (Fig. 
35Y). 

Treatment. — Dupuytren,  in  1829,  after  a  careful  study  of  the 
anatomy  of  the  deformity,  came  to  the  conclusion  that  it  was 
not  only  incurable  but  that  palliation  of  its  effects  even  was 


Bilateral  dislocation  in  adoles- 
cence. This  patient  was  practi- 
cally disabled  by  pain  and  weakness. 


548  OSTHOFEDIC  SUBGEEY. 

hardly  attainable :  and  for  sixty  years  the  statement  was  gen- 
erally accepted,  althotigh  cures  were  attained  in  all  probability 
by  Pravaz.  of  Lyons.  1S47,  and  at  a  much  later  time  by  Paci, 
of  Pisa.  1SS7. 

The  term  dislocation  naturally  suggests  replacement  and  re- 
tention of  the  displaced  bone  in  its  proper  place,  and  in  1S90 
Hoffa  first  performed  this  operation  with  success  by  opening  the 
joint  from  Ix-hind  and  enlarging  the  rtidimentary  acetabulum 
to  a  size  sufficient  to  contain  the  head  of  the  bone.  The  details 
of  the  023eration  were  afterward  modified  by  Loreuz.-^  and  at 
the  present  time  the  original  operation  has  been  to  a  gTeat  ex- 
tent supplanted  by  bloodless  reposition,  but  to  Hoffa  belongs  the 
credit  for  the  introdtictiou  of  the  modern  treatment  of  this 
disability. 

Treatment  by  the  Lorenz  Operation  of  Bloodless  Reduction, 
Retention,  and  Weight  Bearing. — This  treatment  is  based  on 
the  experience  obtained  by  the  open  treatment  that  an  aceta- 
bulum of  fair  size  is  practically  always  present  and  of  sufficieni: 
capacity  to  retain  the  head  of  the  femur  if  the  limb  is  fixed  in  a 
favorable  attitude. 

It  has  been  proved.  al.~o.  that  the  head  of  the  femur  in  most 
instances  may  be  forced  within  the  rudimentary  acetabulum. 
Once  this  contact  or  reposition  is  attained,  the  limb  must  be 
fi:xed  to  prevent  displacement,  and  as  soon  as  possible  the  patient 
must  stand  and  walk  in  order  that  weight  and  friction  may 
deepen  the  rtidimentary  acetabulum.  Meanwhile  the  capsule 
and  other  tissues  adapt  themselves  to  the  new  condition,  while 
the  muscles  regain  their  capacity  for  normal  function.  That 
the  acetabulum  may  be  actually  enlarged  by  the  presence  of  the 
head  of  the  femur  is  proved  by  the  fact  that  secondary  depres- 
sions of  sufficient  size  to  form  joints  of  fair  stability  are  often 
found  upon  the  pelvis  in  anatomical  specimens  from  older 
subjects. 

The  Lorenz  Operation. — The  first  step  in  the  typical  oj^eration 

is  to  overcome  the  resistance  of  the  tissues,  namely,  of  the  capsule 

and  of  the  long  muscles  that  have  become  structurally  shortened 

in  accommodation  to  the  upward  displacement  of  the  head  of 

the  femur.      The  second  step  is  to  reduce  the  dislocation,  or 

rather  to  force  the  head  of  the  femur  over  the  posterior  or  upper 

border  of  the  acetabulum.     The  third  is  to  increase  the  security 

^Pathologie  und  Therapie  der  Angebornen  Hiift.  Yerrenkung.  Wieii, 
1895;  ITeber  heilung  der  Angebornen  Hiiftgelenk  Yerrenkung,  Leipzig  u. 
Wien,  1900. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VABA.     549 

of  the  articulation  by  stretching  the  anterior  border  of  the 
capsule.  The  fourth  is  to  fix  the  parts  securely  in  a  plaster 
bandage. 

The  patient  is  placed  upon  a  table  with  a  thick  folded  sheet 
beneath  the  buttocks.  The  assistant,  standing  opposite  the  oper- 
ator, fixes  the  pelvis  with  his  hands  (Fig.  359).  In  some  in- 
stances better  control  is  assured  by  pressing  the  flexed  thigh  of 
the  sound  side  downward  against  the  abdomen,  as  in  the 
Thomas  test  for  flexion  in  hip  disease. 

The  operator  first  flexes  the  thigh  to  a  right  angle  with  the 
body,  then  forcibly  abducts  it,  at  the  same  time  kneading  the 
tense  muscles  with  the  ulnar  border  of  the  hand,  if  necessary 
stretching  and  rupturing  the  fibres  until  the  limb  can  be  forced 

Fig.  359. 


Reduction  of  dislocation  of  the  right  hip.     First  step.     The  operator  overcomes 
the  resistance  offered  by  the  adductors  by  forcible  massage. 


down  to  the  plane  of  the  body.  One  next  overcomes  the  short- 
ening of  the  tissues  on  the  posterior  aspect  by  flexing  the  limb, 
extended  at  the  knee,  upon  the  trunk,  gradually  forcing  it  down- 
ward until  the  toes  may  be  placed  against  the  patient's  face 
(Fig.  360).  During  this  manoeuvre  the  assistant  fixes  the  pelvis 
by  holding  the  extended  thigh  of  the  sound  side  firmly  against 
the  table.  The  next  step  is  to  overcome  the  resistance  of  the 
tissues  on  the  front  of  the  joint.  The  pelvis  is  fixed  by  the 
assistant.     The  leg  is  then  flexed  upon  the  thigh,  and  the  thigh 


550 


OBTHOPEDIC  SURGE  BY. 
Fig.  360. 


Forcible  flexion  of  the  extended  limb   on  the   abdomen.      Second  step  in   the 

operation. 


Fig.  361. 


Forcible  extension  of  the  thigh.     Third  step  in  the  operation. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VAEA.     551 

is  forced  downward  behind  the  plane  of  the  body,  or  the  patient 
may  be  turned  upon  the  side,  as  in  Eig.  361.  After  this  pre- 
liminary stretching,  traction  is  made  upon  the  limb,  and  if 
with  slight  effort  the  trochanter  can  be  drawn  down  to  ISielaton's 
line  reduction  is  attempted. 

Reduction. — The  pelvis  having  been  fixed  as  in  the  first  posi- 
tion, the  limb  is  slowly  and  forcibly  abducted  over  a  wedge  of 
wood  suitably  padded,  the  apex  of  which  is  placed  between  the 
trochanter  and  the  pelvis  (Fig.  362).  As  the  limb  is  gradually 
forced  downward  to  and  behind  the  plane  of  the  body,  the  head 
of  the  femur  is  forced  upward  until  it  finally  snaps  over  the  pos- 
terior border  of  the  acetabulum.     Reduction  is  usually  accom- 

FiG.  362. 


Reposition.  The  thigti  is  forcibly  abducted  over  the  padded  wedge.  Fourth 
step  in  the  operation.  The  wedge  is  of  hard  wood  of  the  following  dimensions  : 
length,  9%  inches;  height,  3%  inches;  base,  3  inches. 

panied  by  a  distinct  jar,  and  often  by  an  audible  thud.  It  is 
also  indicated  by  tension  upon  the  posterior  muscles  of  the  thigh, 
which  causes  fixed  flexion  of  the  leg.  The  patient  is  then  turned 
upon  the  sound  side  and  the  pelvis,  having  been  fixed  by  the 
assistant,  the  operator  rotates  the  limb  from  side  to  side  and  at 
the  same  time  presses  the  trochanter  downward  and  forward 
with  the  aim  of  forcing  the  head  more  completely  within  the 
acetabulum.  The  security  of  the  reposition  is  then  determined. 
One  tests  successively  the  stability  or  depth  of  the  superior 
margin  of  the  acetabulum  by  reducing  the  abduction;  of  the 
posterior  margin  by  lifting  the  thigh  ventralward,  and  in  a 
similar  manner  the  inferior  border.  Upon  this  examination 
the  prognosis  is  made ;  if  the  stability  allows  an  approximation 
to  the  normal  position  before  displacement  occurs  the  prognosis 
is  good.  If,  on  the  other  hand,  the  margins  of  the  acetabulum 
are  so  ill-formed  that  elisplacement  occurs  very  easily  the  prog- 
nosis is  bad. 


552 


OETHOPEDIC  SrSGESY. 


The  operation  is  varied  somewliat  in  certain  instances.  If 
after  the  stretching  the  trochanter  still  remains  above  Xelaton's 
line,  one  attempts  to  overcome  the  remaining  resistance  by 
direct  traction  in  the  line  of  the  body.  Counter-resistance  is 
furnished  by  a  folded  sheet  passed  between  the  thighs  about  the 
perineum,  the  two  ends  of  which  are  tied  about  a  corner  of  the 
table.  Traction  on  the  limb  is  made  by  one  or  two  assistants 
while  the  operator  supports  the  pelvis  and  presses  downward 
and  inward  upon  the  trochanter.      Occasionally  reposition  is 

Fig.  363. 


Reposition  in  young  subjects,  the  thumb  being  used  as  the  fulcrum  to  I'educe  the 

left  hip. 


effected  during  this  manoeuvre — that  is.  the  head  is  drawn  over 
the  superior  instead  of  the  posterior  border  of  the  acetabulum. 

Preliminary  Traction,^ — In  the  treatment  of  older  patients  or 
of  more  resistant  cases  preliminary  traction  in  bed  is  advisable. 
The  traction  must  be  considerable,  and  heavy  weights,  if  pos- 
sible up  to  forty  pounds  or  more,  should  be  employed  for  two  or 
more  weeks.    This  is  of  great  advantage. 

Reduction  in  Two  Sittings. — If  the  reduction  is  more  than 
usually  difficult,  requiring  more  force  than  is  deemed  safe,  the 
limb  should  be  fixed  in  a  plaster  spica  in  the  attitude  of  abduc- 
tion, the  actual  reposition  being  deferred  for  one  or  more  weeks. 
At  the  second  operation  the  reduction  can  be  easily  accomplished 
in  most  instances. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     553 

Reduction  in  Young  Subjects. — In  younger  subjects  the  wedge 
is  not  necessary,  the  thumb  of  the  OiDerator  being  used  as  a 
fulcrum  beneath  the  trochanter  to  lift  and  push  the  head  up- 
ward while  the  limb  is  abducted.  In  this  class  of  cases  much 
less  force  is  required  in  the  preliminary  stretching,  rupture  of 
the  adductors  is  not  required  (Fig.  363)  and  in  the  treatment 
of  very  young  subjects  reduction  may  often  be  effected  by  simply 
abducting  the  limb. 

After  reposition  has  been  accomplished  and  when  the  greatest 
possible  stability  is  assured  the  plaster  bandage  is  aj)plied.  A 
close-fitting  stockinette  shirt,  of  which  one-half  has  been  cut  and 
sewed  to  cover  the  limb  as  a  drawer,  is  drawn  on  over  the  limb, 

Fig.  364. 


The  position  in  which  the  limb  is  held  when  the  plaster  bandage  is  applied. 

threaded  as  it  were,  with  a  long  bandage,  the  "  scratcher."  The 
patient  is  then  placed  upon  the  pelvic  rest  and  the  limb  is  held 
in  the  position  of  greatest  stability  at  a  right  angle  with  the 
trunk  and  lying  behind  the  plane  of  the  body.  The  pelvis  and 
thigh  are  thoroughly  and  thickly  covered  with  layers  of  sheet- 
wadding  or  cotton.  This  is  bandaged  firmly,  to  assure  a  slight 
elastic  compression  (Fig.  364). 

The  plaster  spica  is  then  applied.  This  should  be  thick  and 
firm.  The  bandages  are  drawn  snugly  around  the  pelvis  and 
thigh  by  a  series  of  reverses  and  figure-of-eight  turns,  clasping 
the  iliac  crests  and  thoroughly  covering  in  the  buttock.  The 
lower  part  is  cut  away,  to  permit  motion  at  the  knee-joint, 
especial  care  being  taken  to  evert  the  edges  and  thus  to  prevent 


554 


ORTHOPEDIC  SUBGESY. 


pressure.  Tlie  ends  of  the  shirting  are  then  drawn  smoothly 
over  the  bandage  and  are  sewed  to  one  another  (Figs.  365  and 
366). 

The  operation  is  usually  followed  by  swelling  and  discolora- 
tion in  the  adductor  region  and  more  or  less  pain,  of  a  starting, 
spasmodic  character,  especially  when  the  leg  is  moved.  This 
soon  passes  away,  usually  during  the  first  or  second  week,  and 
the  child  is  then  encouraged  to  stand.  As  it  is  only  with  ex- 
treme difficulty  that  the  foot  on  the  operated  side  can  be  brought 
to  the  floor,  a  cork-soled  shoe  from  one  and  a  half  to  three  inches 
in  height  is  usually  worn  to  facilitate  walking. 

Fig.  365. 


A  plaster  bandage  applied  by  Lorenz,   illustrating  the  extreme  thickness   of  the 
pelvic  portion  and  discoloration  of  the  adductor  region. 


As  has  been  stated,  walking  is  encouraged  on  the  theory  that 
weight  bearing  and  the  stimulation  of  functional  activity  will 
increase  the  stability  of  the  joint  by  deepening  the  acetabulum 


and  accentuating  its  boundaries. 


In  most  instances  the  range 


of  extension  at  the  knee  is  for  a  time  somewhat  restricted.  This 
restriction  is  overcome  by  passive  force  and  by  the  voluntary 
effort  of  the  patient.  The  first  bandage  is  retained  from  three 
to  six  months  or  for  a  longer  period,  the  skin  being  kept  in  good 
condition  by  daily  vigorous  rubbing  with  the  band  beneath  the 
supporting  bandage.  In  addition  the  leg  should  be  regularly 
massaged;  after  a  few  weeks  the  bandage  becomes  loose  about 
the  pelvis.  This  will  permit  rubbing  of  the  buttocks.  One  is 
able  also  by  palpation  of  the  anterior  region  to  ascertain  whether 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VAEA.     555 

or  not  the  head  of  the  femur  is  in  proper  position.     In  young- 
children  the  bandage  must  be  changed  as  often  as  it  becomes 

offensive. 

In  six  months  or  when  it  may  be  supposed  that  the  accom- 
modative changes  of  the  muscles  about  the  joint  and  the  contrac- 
tion of  the  capsule  will  prevent  of  redisplacement,  the  limb  is  let 

Fig.  366. 


Unilateral  congenital  dislocation,  showing  the  fixation  bandage.  A  shoe 
with  a  cork  sole  about  two  inches  in  height  should  be  worn  on  the  operated  side, 
while  the  attitude  of  exaggerated  abduction  is  maintained. 

down  somewhat  so  that  the  patient  is  able  to  walk  about  without 
the  aid  of  a  high  shoe.  The  second  bandage  is  retained  for  three 
months  or  more,  and  it  is  then  removed,  the  period  of  retention 
being  from  six  to  twelve  months,  according  to  the  stability  of 
the  joint  at  the  time  of  reduction.  In  the  treatment  of  very 
young  children,  when  in  testing  the  stability  at  the  time  of 


556  OBTHOPEBIC  SUEGEBY. 

operation  the  femur  is  not  displaced,  even  when  the  normal 
position  is  approached,  the  limb  mav  be  fixed  by  the  plaster  in 
a  less  distorted  attitude — what  Lorenz  calls  the  indifferent  posi- 
tion of  flexion,  abduction,  and  outward  rotation. 

So,  also,  when  the  tests  at  the  operation  show  fair  stability  a 
second  bandage  need  not  be  applied  after  a  preliminary  reten- 
tion of  from  six  months,  or  even  a  much  shorter  time  if  proper 
supervision  can  be  provided,  but  it  is  better  to  err  on  the  side 
of  safety  in  the  matter  of  fixation. 

When  the  retention  bandage  is  finally  removed  the  attitude 
of  moderate  abduction  and  outward  rotation  persists  for  a  time, 
in  some  instances  for  several  months.  This  being  an  indication 
of  stability,  is  considered  a  favorable  sign,  and  no  attempt  is 
made  to  correct  it.     If,  on  the  other  hand,  as  in  the  older  class 

Fig.  367. 


Illustrating  the  limitation  of  the  range  of  abduction  in  the  attitude  of  right 
angular  flexion  in  bilateral  dislocation. 

of  patients,  the  fixed  abduction  persists  the  patient  should  be 
anaesthetized  and  the  contracted  tissues  carefully  stretched.  In 
many  cases  of  this  character  the  cause  of  the  distortion  is  a  par- 
tial pubic  displacement,  the  head  of  the  bone  forming  a  well- 
marked  projection  beneath  the  femoral  artery.  This  projection 
may  be  reduced  by  flexing  the  limb,  and  in  certain  instances  it  may 
be  well  to  fix  the  limb  for  a  time  in  a  slightly  flexed  position  until 
the  tendency  toward  the  anterior  displacement  is  lessened.  In 
the  after-treatment  the  limb  is  massaged,  particularly  the  pos- 
terior and  lateral  muscles  of  the  hip,  and  the  child  is  encouraged 
to  abduct  and  to  extend  the  thigh,  and  bearing  the  weight  on 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VABA.     557 

the  operated  limb  to  sway  the  other  limb  laterally  to  the  ex- 
treme limit.  Passive  movements  are  made,  also,  in  the  direc- 
tion of  abduction  and  extension,  the  ability  to  reproduce  the 
first  or  operation  position  during  the  early  treatment  being- 
considered  essential.  In  certain  instances  the  child  for  a  time 
should  sleep  in  this  position,  the  attitude  being  assured  by  plac- 
ing the  child  in  a  support  of  plaster  corresponding  to  the  pos- 
terior half  of  the  original  spica. 

Bilateral  congenital  dislocation  is  treated  in  the  same  man- 
ner as  the  unilateral.  Both  hips  are  operated  upon  at  one  sit- 
ting, and  are  fixed  in  the  typical  attitude  (Fig.  371).  Walk- 
ing is,  of  course,  difiicult,  but  the  child  is  usually  able  to  stand, 
and  after  several  months  it  is  often  able  to  get  about  on  its  feet 
after  a  fashion. 

Fig.  368. 


The  after-treatment  following  the  removal  of  the  bandage  in  a  ease  of  bilateral 
dislocation,    illustrating    hyperextension    of    the    thighs. 


When  the  second  bandage  is  applied  the  limbs  are  let  down 
somewhat,  but  the  degree  depends,  of  course,  on  the  initial  sta- 
bility. The  after-treatment  is  the  same  as  for  the  single  dislo- 
cation, except,  of  course,  that  the  subsequent  period  of  awk- 
wardness is  much  longer.  Massage  and  exercises  (Fig.  368) 
are  far  more  important  than  in  single  dislocation,  as  the  weak- 
ness is  greater.  The  primary  position  during  sleep  may  be 
assured  by  a  cushion  roll  or  wooden  frame  as  used  by  Lorenz. 


558 


OETEOPEDIC  SUEGEEY. 


The  Treatment  of  Congenital  Dislocation  in  Infancy^ — At  tlie 
jjresent  time  in  contrast  to  former  years  one  often  lias  the  oppor- 
tiinitj  to  treat  congenital  dislocation  in  infancy  and  early 
childhood.  The  details  of  treatment  do  not  differ  essentially 
from  those  already  described,  except,  of  course,  that  reduction 
is  easily  effected  (Fig.  363)  and  that  walking  or  weighting, 
functional  use  in  other  words,  cannot  always  be  utilized  at 
once  in  the  after-treatment.     In  this  class  of  cases,  provided  the 

Fig.  369. 


Axillary   abduction. 


test  of  the  stability  of  the  joint  is  satisfactory,  one  need  not  fix 
the  limb  in  the  extreme  position.  It  is  well,  however,  to  carrj 
the  bandage  below  the  knee  in  order  to  assure  for  a  time  more 
complete  fixation.  The  support  must  be  renewed  whenever 
sanitary  reasons  indicate  the  necessity.  In  many  instances  cure- 
is  practically  assured  in  a  few  months.  Upwards  of  150  cases, 
of  this  class  have  been  treated  by  the  writer. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     559 

Variations  in  the  Treatment. — It  has  been  stated  that  the  first 
indication  of  failure  was  ordinarily  a  slight  lateral  displace- 
ment of  the  head  to  the  outer  side  of  the  femoral  artery,  and  that 
this  displacement  was  favored  by  the  anterior  torsion  of  the 
upper  extremity  of  the  femur.  As  is  well  known,  anterior  tor- 
sion of  moderate  degree  is  not  unusual  in  the  femora  of  ap- 
parently normal  joints.  Furthermore  anterior  torsion  is  always 
more  marked  in  early  than  in  later  life.  According  to  Le 
Damany,  at  birth  the  torsion  angle  is  from  30—60°,  from  2—4 
years  35°,  6-12  years  25-30°,  in  adult  life  10-12°,  and  it 
may  not  therefore  be  a  serious  obstacle  to  successful  treatment 
in  early  childhood.  If,  however,  anterior  torsion  is  suspected 
or  is  known  to  exist,  and  if  displacement  has  recurred  after  the 
operation  it  is  well  to  rotate  the  thigh  inward,  so  that  the  head 
of  the  femur  lies  slightly  to  the  inner  side  of  the  artery,  and  to 
fix  it  in  this  attitude  by  extending  the  plaster  bandage  below 
the  knee,  the  leg  being  slightly  flexed  upon  the  thigh.  This 
attitude  should  be  retained  untik  it  may  be  assumed  that  the 
capsule  is  sufficiently  contracted  to  restrain  the  femur  from 
reluxation. 

In  some  instances,  especially  in  anterior  displacement  in 
young  subjects,  the  upper  anterior  border  of  the  acetabulum 
seems  to  offer  no  resistance  to  redisplacement.  One  may  then 
place  the  limb  in  axillary  abduction  (Werndorff),  Fig.  369,  for 
a  month  or  more,  in  the  hope  that  the  upper  border  of  the  cap- 
sule will  contract  sufficiently  to  prevent  redisplacement. 

In  such  cases,  and  in  fact  in  all  cases  in  which  the  upward 
displacement  is  feared,  the  patient  should  be  anaesthetized  when 
the  plaster  is  changed.  One  may  then  hold  the  head  of  the 
femur  in  place  and  stretch  the  contracted  tissues,  particularly 
the  iliofemoral  ligament,  sufficiently  to  permit  the  lessened  ab- 
duction, for  the  resistance  of  these  tissues  seems  in  certain  in- 
stances to  be  the  direct  cause  of  displacement. 

The  writer  often  modifies  the  Lorenz  treatment  in  certain 
details  both  in  unilateral  and  bilateral  cases.  In  the  original 
attitude  of  flexion  and  extreme  abduction  the  head  of  the  femur 
is  not  within  the  acetabulum  but  is  pressed  against  the  anterior 
wall  of  the  capsule.  This  attitude  is  of  advantage  in  that  it 
enlarges  the  capacity  of  the  joint  anteriorly  and  permits  re- 
traction of  the  posterior  sac  which  originally  formed  the  joint. 
These  changes  it  may  be  assumed  have  in  a  young  subject  be- 
come sufficiently  advanced  at  the  end  of  three  months  to  permit 


560 


OETHOPEDIC  SUBGEBY. 


more  accurate  reposition.     The  patient  is  again  anaesthetized 
and  while  by  pressure  on  the  trochanter  the  head  of  the  bone 


Fig.  370. 


Illustrating  the  range  of  normal   abduction   of  the  thighs,  from   the  attitude  of 
right  angular  flexion. 

Fig.  371. 


The  bandage  applied  after  the  reduction  of  bilateral  dislocation,  showing  a 
favorite  method  of  progression  on  a  chair. 


is  held  in  its  original  position  the  contraction  of  the  tissues  that 
resist  adduction  is  overcome  and  the  limb  is  rotated  inward 
until  the  patella  points  directly  forward,  a  plaster  bandage  is  then 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VABA.     56 1 

applied  to  fix  the  limb  in  extension  and  in  from  15  to  45°  of  abduc- 
tion according  to  the  stability  of  the  reposition.  This  bandage  is 
often  extended  to  the  ankle  in  order  to  fix  the  limb  in  slight 
inward  rotation  by  accurate  adjustment  about  the  knee.  In 
this  position  the  head  of  the  femur  is  placed  as  well  as  may  be 
within  the  acetabulum  and  the  weight  of  the  body  in  standing 
and  walking  is  brought  more  directly  into  use  in  functional 
reconstruction.  The  second  period  of  fixation  is  for  about  the 
same  length  of  time.  The  procedure  may  be  again  repeated  if 
it  seems  desirable,  the  period  of  retention  being  determined  by 
the  original  stability,  by  subsequent  tests,  and  by  X-ray  pictures. 
In  all  doubtful  cases  fixation  should  be  prolonged  to  a  period  of 
at  least  one  year. 

Prognosis. — The  Lorenz  operation  in  older  subjects  is  not 
without  danger.  The  death-rate  attributed  to  anaesthesia  is  dis- 
proportionately large  in  the  cases  reported,  and  in  this  the 
violence  of  the  manipulations  is  undoubtedly  an  important 
factor. 

In  450  operations  reported  by  Lorenz  the  following  accidents 
occurred : 

Fracture  of  the  neck  of  the  femur  in 11  cases 

Fracture   of   the   pelvis   in 3  cases 

Peroneal   paralysis   in 3  cases 

Crural   paralysis    in 5  cases 

Sciatic  paralysis  in 3  cases^ 

In  the  last  cases  the  paralysis  persisted ;  in  the  others  it  was 
temporary.  In  one  case  the  femoral  artery  was  ruptured,  the 
patient  recovering  without  ill-eifect.  In  one  case  gangrene  of 
the  extremity  necessitated  amputation  at  the  hip-joint. 

It  may  be  stated,  however,  that  in  the  younger  class  of  cases 
the  operation,  if  conducted  with  reasonable  regard  to  the  resist- 
ance of  the  tissues  and  to  the  susceptibility  of  the  patient,  is 
practically  free  from  danger. 

In  cases  treated  at  the  proper  age — that  is,  under  six  years 
for  bilateral  and  under  eight  for  unilateral  cases — about  50 
per  cent,  of  the  unilateral  and  25  per  cent.  (50  per  cent,  for 
each  side)  of  the  bilateral  cases  can  be  anatomically  and  func- 
tionally cured,  the  percentage  being  of  course  far  higher  in 

^  Eighty-eight  cases  of  paralysis  induced  by  the  operation  have  been 
tabulated  by  Bade,  from  1-3  per  cent,  of  the  cases  reported  by  various 
surgeons.  In  16  the  peroneal  nerve  was  involved,  in  61  the  sciatic  and  in 
11  the  paralysis  of  the  limb  was  complete.  Eecovery  is  the  rule  in  from  3 
to  8  months.     Verhandlung  d.  Gesel.  f.  Orth.  Chir.,  1909. 

36 


562 


ORTHOPEDIC  SUBGEET. 


Fig.  372. 


the  cases  in  wliicli  at  operation  the  reduction  is  found  to  be  of 
fairly  secure  type.  Lorenz  claims  success  in  358  of  680  cases 
treated,  52.6  per  cent.^  l^early  all  the  others  can  be  greatly 
improved,  in  that  the  posterior  displacement  may  be  converted 

into  an  anterior  one.  In  such 
cases,  in  which  the  head  of  the 
femur  is  forced  forv^ard  below  the 
anterior  superior  spine,  the  static 
conditions  become  approximately 
normal,  and  further  displacement 
is  to  a  great  extent  prevented  by 
the  firm  tissues  attached  at  this 
point.  A  stable  articulation  is 
assured  by  long  retention  of  the 
limb  in  the  position  of  abduction 
and  extension  by  means  of  the 
plaster  bandage  and  by  exercises 
and  passive  movements  after  its 
removal. 

As  has  been  stated,  in  success- 
ful cases  the  head  of  the  femur  can 
always  be  palpated  directly  be- 
neath the  femoral  artery.  The 
first  indication  of  failure  is  a 
slight  lateral  displacement  of  the 
head  to  the  outer  side  of  the  ar- 
tery. This  may  appear  even  dur- 
ing the  period  of  fixation,  and 
cases  should  be  systematically  ex- 
amined for  such  failure  by  palpat- 
ing the  head  of  the  femur  beneath 
the  bandage;  usually,  however,  it 
is  not  apparent  until  the  plaster 
bandage  is  removed.  At  first  there 
is  no  shortening,  but  slowly,  as  the 
displacement  increases  and  as  the 
head  of  the  bone  ascends  from  the 
neighborhood  of  the  acetabulum  to 
that  beside  or  above  the  anterior  inferior  pelvic  spine,  this  be- 
comes evident.  At  first  it  is  half  an  inch,  later  an  inch,  but  it  is 
not  often  m.ore  than  this,  at  least  during  childhood. 
1  American  Medicine,  June  18,  1904. 


The  cure  of  congenital  disloca- 
tion. The  same  patient  is  shown 
in   Fig.   366. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     563 

It  has  been  stated  that  this  outcome  may  be  expected  in  about 
half  of  the  favorable  cases  as  to  age  in  which  all  the  details  of 
the  operation  have  been  properly  carried  out,  and  it  is  the  usual 
result  in  the  unfavorable  class.  This  result,  which  is  not  classed 
by  Lorenz  as  a  failure,  but  rather  as  an  improvement,  may  be 
explained  in  certain  instances  by  interposition  of  a  fold  of  cap- 
sule between  the  head  of  the  bone  and  the  acetabulum,  or  by 
failure  of  the  process  of  reformation  of  the  acetabulum.  In 
many  cases,  however,  it  is  accounted  for  by  an  anterior  twist 
of  the  upper  extremity  of  the  femur,  so  that  the  neck  instead  of 
pointing  inward  and  slightly  forward  from  the  shaft  is  turned 
forward  and  slightly  inward.  Thus,  in  order  to  replace  the 
head  in  the  acetabulum,  the  limb  must  be  rotated  inward  until 
the  foot  points  inward  rather  than  forward. 

It  is,  of  course,  apparent  that  the  only  remedy  is  a  cutting 
operation.  Lorenz  is  content  in  these  cases  with  anterior  appo- 
sition, but  if  it  is  probable  that  a  twist  in  the  upper  extremity 
of  the  femur  is  alone  responsible  for  failure,  it  seems  more 
reasonable  to  remove  this  by  osteotomy.  This  operation  will  be 
described  in  connection  with  the  open  operation. 

The  Treatment  of  Older  Subjects, — It  has  been  stated  that  the 
final  result  in  a  very  large  proportion  of  the  operations  was 
anterior  transposition  or  apposition,  as  Lorenz  calls  it,  and  that 
in  cases  beyond  the  age  of  eight  years  this  result  is  to  be  ex- 
pected. In  this  class  of  cases — from  ten  to  twenty-one  years  of 
age — it  is  the  primary  aim  of  the  operation.  After  preliminary 
traction  in  bed  and  after  subcutaneous  division  of  the  more  re- 
sistant tendons  if  this  is  necessary,  the  limb  is  forced  into 
moderate  abduction  and  extreme  extension,  so  that  the  head  of 
the  bone  is  displaced  forward  to  the  neighborhood  of  the  anterior 
inferior  spinous  process.  In  this  attitude  the  limb  is  retained 
for  many  months  by  means  of  the  plaster  bandage,  and  it  is 
assured  in  the  after-treatment  by  the  manipulation  and  ex- 
ercises already  described.  Although  even  in  the  most  success- 
ful cases  a  limp  persists,  yet  it  is  far  less  noticeable  than  in 
untreated  cases,  the  discomfort  is  relieved,  the  limb  is  length- 
ened, and  the  danger  of  future  disability  is  much  lessened. 

In  those  unusual  cases  in  which  the  adduction  and  flexion 
deformity  is  extreme,  osteotomy  of  the  femur  may  be  required, 
and  if  the  pain  is  persistent  excision  of  the  hip  may  be  nec- 
essary. 


564 


OBTROPEDIC  SUEGEBY. 


Arthrotomy. — If  the  Lorenz  operation  has  failed  when  all  the 
details  have  been  thoroughly  carried  out,  the  advisability  of  an 
exploratory  operation  suggests  itself.  Under  proper  aseptic 
precautions  this  should  entail  no  danger  nor  should  it  compro- 
mise the  functional  ability  of  the  joint.     One  can  then  assure 


Fig.  373. 


Fig.  374. 


r 


^  w 


A  successful  result  after  the  open  opera- 
tion, illustrating  a  form  of  brace  to  be  used 
in  the  after-treatment  to  hold  the  limb  in 
proper  position  if  it  has  a  tendency  to 
rotate  outward. 


Bilateral  dislocation  six 
months  after  replacement  by 
the  open  method  in  1807,  il- 
lustrating the  change  in  the 
contour  of  the  spine. 


one's  self  that  the  head  of  the  bone  is  actually  replaced  within 
the  acetabulum.  Arthrotomy  is  indicated  also  if  the  resistance 
to  reposition  by  the  ordinary  method  is  so  great  that  dangerous 
force  must  be  exerted  to  overcome  it. 

The  joint  is  exposed  by  a  lateral  incision  about  three  inches 
in  length,  extending  downward  from  a  point  about  three-quar- 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VAEA.     565 

ters  of  an  inch  to  the  outer  side  of  the  anterior  superior  spine 
of  the  ilium,  the  fascia  is  divided,  and  the  line  of  junction  be- 
tween the  tensor  vaginae  femoris  and  the  gluteus  niedius  muscles 
is  found.  These  muscles  are  then  sej^arated  and  are  drawn  to 
either  side  by  retractors,  thus  exposing  the  capsule  of  the  joint. 
This  is  opened  by  an  incision  parallel  to  the  neck  of  the  bone. 
The  finger  is  then  passed  through  the  opening,  down  upon  the 
rudimentary  acetabulum.  A  strong  cervix  dilator  is  next  in- 
serted and  the  contracted  capsule  is  thoroughly  stretched.  If 
the  ligamentum  teres  is  present  it  is  removed. 

The  head  is  then  replaced;  the  capsule  and  overlying  tissues 
are  united  with  catgut  sutures.  The  limb  is  then  fixed  in  the 
typical  position  by  the  Lorenz  spica.  In  the  majority  of  cases 
the  cause  of  the  failure  of  the  primary  operation  is  an  antever- 
sion  of  the  neck  of  the  femur.  In  this  event  after  replacement 
the  limb  must  be  rotated  inward  to  the  required  degree  and  fixed 
by  a  plaster  bandage  extending  below  the  knee  as  a  preliminary 
to  osteotomy. 

Osteotomy. — In  those  cases  in  which  the  anterior  torsion  is  so 
great  that  displacement  must  recur  whenever  the  limb  is  used 
in  the  normal  attitude,  osteotomy  is  indicated.  The  dislocation 
is  first  reduced  by  abduction  and  extreme  inward  rotation  of 
the  limb  and  the  limb  is  fixed  in  this  attitude  for  several  months 
until  fair  stability  is  assured.  The  plaster  support  is  then  re- 
moved, the  limb  being  held  in  the  attitude  of  inward  rotation 
to  prevent  displacement. 

A  long  drill  fixed  in  a  handle  is  pushed  through  the  shaft  just 
below  the  neck.  A  subcutaneous  osteotome  is  then  inserted  at 
a  point  just  below  the  trochanter  minor  and  a  thorough  division 
of  the  bone  is  made.  When  the  division  is  complete,  the  upper 
fragment  being  fixed  by  holding  the  j^rojecting  drill,  the  limb 
is  rotated  outward  until  the  normal  relation  between  the  shaft 
and  the  neck  is  restored.  A  plaster  spica  including  the  foot  is 
then  applied,  the  turns  being  made  about  the  drill  so  that  out- 
ward rotation  of  the  ujDper  fragment  is  prevented.  Several 
weeks  later,  when  the  improved  position  is  assured,  this  is  with- 
drawn. The  after-treatment  is  the  same  as  in  the  uncompli- 
cated cases. 

The  Open  Operation  with  Enlargement  of  the  Acetabulum. — The 
original  Hoffa-Lorenz  ojjeration,  once  the  treatment  of  routine, 
is  now  reserved  for  a  restricted  class  of  cases  in  which  the  blood- 
less operation  has  failed,  or  in  which  on  opening  the  joint  the 
acetabulum  is  found  to  be  notablv  deficient. 


566 


OETHOPEDIC  SUEGEEY. 


Supposing  the  shortening  of  the  limb  to  have  been  overcome 
bj  previous  treatment,  the  joint  and  capsule  are  opened  in  the 
manner  already  described.  One  finger  is  then  inserted  to  the 
acetabulum  and  by  its  side  a  strong,  sharp  bayonet-shaped  spoon 


Fig.  375. 


Scoops    used  in   the   treatment   of   congenital    dislocation,    also   the   subcutaneous 

osteotome. 


(Fig.  375)  is  passed,  and  with  it  the  shallow  acetabulum  is  en- 
larged to  a  sufficient  size,  care  being  taken  to  accentuate  its  supe- 
rior and  posterior  border.  The  head  is  then  placed  within  it, 
and  the  wound  is  closed  or  packed  according  to  the  custom  of 
the  operator,  Hoffa,  who  was  the  principal  exponent  of  the 
operation,  made  an  oblique  incision  from  the  anterior  superior 
spine  downward  and  backward  over  the  trochanter  and  exposing 
the  joint  between  the  gluteus  medius  and  minimus  muscles. 
He  usually  employed  the  Doyen  instrument  to  bore  out  a  very 
capacious  acetabulum  after  reposition.  A  long  plaster  spica  is 
apjilied  with  the  limb  in  an  attitude  of  moderate  abduction 
and  extension.  In  a  month,  or  when  repair  is  complete,  a  short 
Lorenz  spica  is  applied  and  the  patient  is  encouraged  to  walk 
about.     This  support  should  be  worn  for  from  six  months  to  a 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     567 

year  in  order  to  prevent  the  contractions  that  almost  inevitably 
follow   operations   of   this   character.      Exercise   and    forcible 

Fig.  376. 


Unsuccessful  treatment  by  forcible  correction   (Lorenz  operation).     The  posterior 
has  been  changed  to  an  anterior  displacement.      Rear  view. 

manipulation  v^ithin  a  few  weeks  after  the  operation,  as  recom- 
mended by  many  writers,  are  not  only  of  no  service,  but  in  the 
author's  experience,  harmful. 


568  ORTHOPEDIC  SUBGEEY. 

When  the  spica  is  removed  and  the  patient  is  allowed  to  run 
about,  motion  usually  returns.  At  this  time  massage  should  be 
employed  and  passive  movements  always  in  extension  and  ab- 
duction. Later,  gymnastic  training  is  of  great  value.  After 
this  operation,  provided  there  is  true  anatomical  cure,  motion 
is  usually  restricted  to  a  greater  or  less  degree,  and  in  older  sub- 
jects there  is  often  fibrous  anchylosis.  For  this  reason  it  should 
be  limited  to  unilateral  cases,  or,  at  all  events,  one  should  never 
operate  on  the  second  hip  until  the  result  of  the  operation  in 
the  first  is  known.  In  unilateral  cases  anchylosis  without  de- 
formity is  not  a  serious  functional  disability,  as  there  is  solid 
support  without  shortening ;  while  if  fair  motion  is  obtained,  as 
in  many  instances,  the  functional  result  is  far  better  than  after 
simple  transposition.  It  should  be  stated  that  even  after  the 
open  operation  this  transposition  is  often  the  outcome.  In  such 
cases  motion  is,  of  course,  free  and  the  stability  is  somewhat 
greater  than  after  the  bloodless  operation.  If  after  this  opera- 
tion motion  is  extremely  limited  one  must  expect  flexion  and 
adduction  deformity  unless  it  be  prevented  by  careful  treat- 
ment. In  certain  instances  the  range  of  motion  may  be  in- 
creased by  breaking  up  adhesions  and  stretching  the  contracted 
parts  under  anaesthesia. 

The  danger  of  the  operation  is  slight,  and  the  deaths,  with 
but  few  exceptions,  have  been  due  to  infection.  Lorenz  and 
Hoifa  lost  several  of  their  earlier  patients  from  this  cause,  but 
with  improved  technique  the  danger  is  slight.-^  The  bad  results 
of  the  operation  may,  as  a  rule,  be  accounted  for  by  its  improper 
performance,  particularly  the  failure  to  replace  the  femur  se- 
curely, or  by  failure  to  ensure  asepsis,  or  by  inefficient  super- 
vision and  after-treatment. 

It  is  perhaps  unnecessary  to  state  that  operations  of  this  char- 
acter should  not  be  performed  unless  asepsis  can  be  assured, 
unless  the  operator  is  familiar  with  the  anatomy  of  the  parts, 
and  unless  the  essential  after-treatment  can  be  provided. 

Review  of  the  Treatment  of  Congenital  Dislocation  of  the 

Hip.- — The  prospect  of  success  in  treatment  stands  in  direct  re- 
lation to  the  age  of  the  patient,  since  the  degree  of  the  patho- 
logical changes,  that  make  cure  difficult  or  impossible,  depends 
as  in  a'cquired  dislocations,  upon  the  duration  of  the  disability. 

^  Hoffa  has  performed  the  operation  248  times,  with  10  deaths,  8  due  to 
the  operation,  the  last  132  operations  without  a  death.  Lorenz,  in  260 
operations,  lost  4  patients  from  septica'mia. — Eeport  of  the  Thirteenth 
International  Congress,  Paris,  August,  1900. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VABA.     569 


Consequently,  treatment  should  be  applied  as  soon  as  the  dis- 
placement is  discovered,  and,  as  has  been  stated,  there  is  little 
excuse  for  not  making  the  correct  diagnosis  when  the  child  be- 


FiG.  377. 


Fig.  378. 


Unilateral  dislocation.  Two 
years  after  operation  in  1897  by 
the  Lorenz  methiod.  A  complete 
cure. 


Unilateral  dislocation.  Eighteen  months- 
after  operation  by  the  Lorenz  method  in 
1897.     A  complete  cure. 


gins  to  walk.  The  treatment  of  selection  is  the  functional 
weighting  method  of  Lorenz,  modified  somewhat  in  certain 
cases  in  that  the  limb  may  be  placed  with  advantage  in  that 
position  which  best  assures  stability.  In  his  last  communica- 
tion, 1909,  from  an  experience  in  more  than  1000  cases  Lorenz 
states  that  he  has  made  no  essential  change  in  the  operation. 


570 


ORTHOPEDIC  SURGE E¥. 


In  general  he  advises  against  complete  rupture  of  the  adductors 
and  against  forcible  increase  of  the  capacity  of  the  joint  by  ro- 
tation and  pressure  at  the  time  of  operation.  The  shortest 
period  of  fixation  in  the  primary  position  should  be  6  months, 
increased  to  8  or  10  in  certain  instances.     By  this  treatment  a' 


Fig.  379. 


Fig. 


^ 


clip 


Cet.-^'' 


ixJj 


Unilateral  dislocation,  after  opera- 
tion by  the  Lorenz  metliod  in  1897. 
A  complete  cure.  Compare  with  Pig. 
351. 


Unilateral  dislocation,  two  years 
after  operation.  Compare  with  Pig. 
352. 


larger  proportion  of  the  cases  may  be  cured,  and  in  all  instances 
the  posterior  may  be  changed  into  an  anterior  displacement, 
which  is  a  great  improvement.  The  treatment  at  the  hands  of  a 
competent  surgeon  in  properly  selected  cases  is  free  from  dan- 
ger, for  now  that  the  strain  that  the  tissues  will  safely  withstand 
is  better  known,  violent  and  prolonged  manipulation  has  been 
discarded.     In  the  older  class,  or  when  reduction  is  difficult, 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VABA.     571 

the  resistant  parts  should  be  stretched  by  preliminary  traction 
in  bed,  or  the  reduction  should  be  accompanied  at  two  sittings. 

If  one  is  not  content  with  functional  improvement  in  the  cases 
in  which  anatomical  cure  has  not  been  attained  the  treatment 
may  be  supplemented  by  arthrotomy,  and  if  anteversion  of  the 
upper  extremity  of  the  femur  prevents  success  it  may  be  rem- 
edied by  osteotomy. 

Excavation  of  the  acetabulum  will  often  assure  anatomical 
success. 

Anatomical  reposition  with  fair  or  even  very  limited  motion 
assures  better  function  in  unilateral  cases  than  transposition, 
but  anchylosis  with  deformity  is  certainly  no  improvement  on 
the  original  condition.  It  may  be  suggested,  also,  that  the  dan- 
gers of  open  operation  even  if  slight  must  be  considered. 

In  the  treatment  of  adolescent  cases  one  should  attempt  to 
obtain  anterior  transposition  and  to  assure  it  by  fixing  the  limb 
for  a  sufficient  time  in  the  improved  position. 

Palliative  Treatment. — Palliative  treatment  does  not  require 
extended  comment.  In  brief,  in  unilateral  cases  a  cork  sole 
may  be  worn  to  equalize  the  length  of  the  limbs,  and  in  bilateral 
cases  a  corset  suitably  strengthened  with  steel  supports  may  be 
adjusted  if  the  lordosis  is  extreme.  Exercise  and  passive 
manipulation  with  the  aim  of  retaining,  as  far  as  possible,  the 
ability  to  abduct  and  to  extend  the  thighs  may  be  of  service  in 
preventing  secondary  contractions.  Overexertion  that  causes 
discomfort  or  pain  should  be  avoided. 

CONGENITAL  SUBLUXATION  OF  THE  HIP. 

•  As  has  been  stated,  there  are  cases  of  congenital  displacement 
of  the  hip  which  are  in  reality  subluxations.  In  such  cases  there 
is  a  slight  limp  and  slight  shortening,  and  an  X-ray  picture 
shows  a  secure  acetabulum  somewhat  above  the  plane  of  the 
opposite  side.  These  subluxations  are  always  of  the  anterior 
variety.     They  should  be  treated  in  the  ordinary  manner. 

SNAPPING  HIP. 

Some  individuals  possess  the  power  of  slightly  displacing  the 
hip,  usually  upon  the  superior  or  upper  border  of  the  acetabu- 
lum. This  is  sometimes  seen  in  infancy,  the  child's  thigh  snap- 
ping with  a  jar  or  even  audible  sound  upward  and  downward. 
This  is  usually  accomplished  when  the  child  is  seated  in  the 


572  OFTHOPEDIC  SrSGEEY. 

mother's  lap.  the  thigh  being  flexed  and  addncted,  and  in  this 
class  of  cases  it  is.  according  to  the  mothers,  an  evidence  of 
temper.  As  the  displacement  mar  he  increased  by  habit,  it  is 
well  to  restrain  it  by  applying  a  bandage  about  the  hip  to  pre- 
vent flexion  of  the  limb,  which  is  apparently  preliminary  to  its 
accomplishment.  (See  Snapping  Knee.)  Snapping  about  the 
hip  in  older  subjects  is  usually  induced  by  friction  between  the 
gluteus  maximus  muscle  and  the  trochanter.  The  limb  flexed  at 
the  knee  is  rotated  inward  and  the  tendinous  attachment  of  the 
gluteus  maximus  springs  backward  on  the  trochanter.  It  is  in 
a  degree  an  accomplishment  which  is  apparently  increased  by 
practice. 

COXA  VARA. 

Synonyms. — Depression  or  incurvation  of  the  neck  of  the 
femur ;  bending  of  the  neck  of  the  femur. 

The  character  of  this  deformity  is  indicated  by  the  synonyms. 
The  term  coxa  vara  signifies  that  its  causes  and  eft'ects  are  simi- 
lar to  those  of  genu  valgum  and  varum,  the  more  common  dis- 
tortions of  the  lower  extremities. 

Genu  valgum  and  varum  are  common  in  childhood,  but  rarely 
develop  in  adolescence.  Coxa  vara  is,  in  comparison,  an  infre- 
quent deformity,  and  it  is  peculiar  in  that  it  more  often  ap- 
pears in  later  childhood  or  adolescence  than  at  the  earlier  period, 
doubtless  because  the  neck  of  the  femur  is,  at  the  age  when 
rhachitic  distortions  are  common,  very  short,  and,  therefore, 
relatively  stronger  than  the  shaft,  while  in  adolescence  the  con- 
ditions may  be  reversed. 

The  distortions  at  the  knee  are  self-evident,  but  the  neck  of 
the  femur  is  concealed  from  view;  thus  the  diagnosis  of  coxa 
vara  may  be  somewhat  difficult;  and,  in  fact,  it  is  only  in  com- 
paratively recent  years  that  its  symptoms  have  been  recognized. 
Fiorani^  first  described  the  deformity  as  it  had  been  observed 
by  him  in  children ;  but  E.  Mliller^  first  called  attention  to  the 
affection  as  one  of  the  deformities  of  adolescence,  which,  until 
that  time,  had  been  mistaken  for  hip  disease. 

Pathology. — The  term  coxa  vara  should  not  be  applied  to  de- 
pression of  the  neck  of  the  femur  that  may  be  secondary  to  de- 
structive disease,  for  example,  to  osteomyelitis,  arthritis  de- 
formans, osteomalacia,  and  the  like,  but  it  should  be  reserved 
for  cases  of  simple  local  deformity.     In  most  instances  the  de- 

'Gazetta  degli  Ospitale,  1881,  Nos.  16,  17. 
^Beitrage  zur  klin.  Chir.,  1889,  Bd.  iv. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VABA.     573 


Fig.  381. 


formity  affects  the  neck  as  a  whole  (cervical  coxa  vara)  ;  in 
others  it  is  most  marked  at  the  epiphyseal  junction  (epiphyseal 
coxa  vara),  Epij)hyseal  coxa  vara  is  more  often  found  in  the 
adolescent  class,  and  particularly  in  those  cases  in  v^hich  the 
symptoms  have  been  induced  or  aggravated  by  injury  or  strain. 
Whether  the  injury  caused  primarily  a  partial  epiphyseal  sepa- 
ration v^hich  afterward  slowly 
increased  under  the  strain  of 
functional  use ;  or  suddenly 
increased  a  pre-existing  dis- 
tortion of  the  weakened  part 
is  sometimes  difficult  to  de- 
cide, but  in  most  instances 
this  type  should  be  classified 
as  fracture  rather  than  as  a 
developmental  deformity.  A 
number  of  specimens  of  coxa 
vara  have  been  examined, 
but  no  changes,  other  than 
such  as  might  be  caused  by 
the  deformity  itself,  have 
been  found.  These  are,  in 
brief,  congestion  and  soften- 
ing of  the  bone,  and  evi- 
dences    of     irritation    within    noiwl  femur  at  eight  yeai^i^  age  ;ang^^^^ 

formed   by    the   neck    with    the    shaft    140 
the  joint   during  the   progres-    degrees,      in  the  normal  subject  the  neck 

sive  stage  of  the  deformity,   °^,t^!*  ^""^V  ^''T'''  ^"s^^f^ /^^-^^^'-^ 

a  ,7  7     (12    degrees)     and    upward    to    form    an 

with    the    general    adaptive  angle  with  the  shaft  of  about  125  de- 
changes     in     all     the     COmpO-  S^ees.   m  childhood  this  angle  is  usually 
"                  _                                 1  somewhat   greater,    and   m    later   years    it 
nentS  of  the  joint  that  always  may  be  somewhat  less  than   125  degrees; 

accom^anv    disnlacement    or   '"^  *''*'*'  ""  ^^"'^t*°°  between  no  and  i40 

d-CLumpany     uispiacemeni     or    (jeg^ees  may  be  within  the  normal  limit.i 

distortion.         These     may     be    Both    anterior    torsion     and    upward    in- 

•  1         11  .       ,      -, .  .        clination  are  much  greater  at   birth  than 

considerable,     including,     in   ■^^  j^jj^,^  uj^ 

advanced  cases,  a  change  in 

the  acetabulum,  whose  upper  border  is  less  sharply  defined  than 

normal. 

Etiology. — Many  writers  assume  that  the  weakness  of  the 
neck  of  the  femur  that  ^predisposes  to  deformity  is  the  result  of 
local  disease,  such  as  so-called  local  rickets  or  local  osteomalacia. 
This  is,  however,  simply  a  convenient  hypothesis.  Others  be- 
lieve the  deformity  to  be  symptomatic  of  late  rickets,  although 
^  Humphrey,  Jour.  Anat.  Phys.,  vol.  xxiii.,  p.  236. 


Section    of    the    upper    extremity    of 


574  OSTHOPEDIC  SUEGEBY. 

evidence  of  general  rhachitis  is  almost  never  present  in  the 
ordinary  type  as  it  appears  in  later  childhood  and  adolescence. 

Coxa  .vara,  at  least  of  the  ordinary  type,  may  be  classed  as 
one  of  the  group  of  static  deformities  of  the  lov^er  extremity 
caused  by  a  disproportion  betv^een  the  strength  of  the  support- 
ing structure  and  the  burden  that  is  put  upon  it.  The  support 
may  be  disproportionately  weak,  because  of  inherited  delicacy 
of  structure;  it  may  be  v^eakened  by  injury  or  by  disease,  or  it 
may  be  overburdened  by  v^eight  or  strain. 

Mechanical  Predisposition  to  Deformity. — In  many  cases  the  pre- 
disposition to  deformity  is  the  result  of  a  lessened  angle  of  the 
femoral  neck.  This  slight  and  predisposing  depression,  which 
is  in  most  instances,  the  effect  of  early  rhachitis,  becomes  exag- 
gerated to  deformity  during  later  childhood  or  adolescence.  In 
this  sense- — that  of  a  remote  result — coxa  vara  in  adolescence 
may  be  classed  as  one  of  the  rhachitic  deformities.  The  impor- 
tance of  this  mechanical  factor  in  the  etiology  was  demonstrated 
to  me  by  the  investigation  of  a  number  of  cases  of  simple  frac- 
ture of  the  neck  of  the  femur  in  childhood.  In  these  cases  the 
neck  of  the  femur  was,  by  the  original  injury,  somewhat  de- 
pressed, and  although  immediate  functional  recovery  followed, 
yet  in  a  number  of  the  cases  j)rogressive  deformity,  attended  by 
the  symptoms  of  typical  coxa  vara,  resulted.  This  could  be  ex- 
plained only  on  the  theory  that  the  lessened  angle,  subjecting  the 
parf  to  greater  strain,  was  the  predisposing  cause  of  the  later 
disability.  Other  factors  in  the  etiology  may  be  general  weak- 
ness, incident  to  rapid  growth,  direct  injury  (fracture),  and  the 
strain  of  occupation.-^ 

In  this  connection  it  may  be  stated  that  fracture  of  the  neck 
of  the  femur  in  childhood  may  cause  a  deformity  which  in  the 
absence  of  a  history  could  not  be  distinguished  from  the  ordi- 
nary form  of  coxa  vara,  of  which,  in  fact,  it  is  the  traumatic 
form.  At  the  present  time  in  the  absence  of  immediate  diag- 
nosis cases  of  fracture  are  still  included  in  coxa  vara,  a  very 
large  proportion  of  the  unilateral  cases  being  of  this  character. 
If  these  might  be  excluded  coxa  vara  would  become  one  of  the 
deformities  due  in  most  instances  to  the  immediate  or  remote 
effects  of  rhachitis.^  (See  Fracture  of  the  Neck  of  the  Femur 
and  Epiphyseal  Separation.) 

^  Several  cases  of  congeBital  coxa  vara  have  been  reported.  In  such  in- 
stances the  deformity  is  often  one  of  many  distortions.  Depression  of  the 
neck  of  the  femur  in  congenital  dislocation  of  the  hip  has  been  mentioned  in 
the  section  on  that  affection. 

=  Whitman,  Zentralblatt  fiir  Chir.,  No.  11,  1910. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     575 

If  tlie  statistics  are  limited  to  the  class  in  whicli  the  deformity 
causes  the  symptoms  for  which  treatment  is  sought  rather  than 
as  one  of  many  deformities  incidental  to  rhachitisit  will  appear 
very  decidedly  as  an  affection  of  late  childhood  and  adolescence. 
It  is  far  more  common  in  males  than  in  females  and  it  is  usually 
unilateral,  facts  that  indicate  the  influence,  of  strain  or  injury  in 
inducing  or  increasing  the  distortion. 

The  points  of  special  interest  in  72  personal  cases  may  be 
summarized  as  follows:  In  about  one-third  of  the  cases  there 
was  a  distinct  history  of  rhachitis  in  infancy.  The  ages  of  the 
patients  were  as  follows  : 

Adolescents,  twelve  to  seventeen 40 

Later  childhood,  five  to  eleven 23 

Early  childhood,  less  than  five 3 

Over  seventeen  years 6 

Total ■ 72" 

In  many  instances  the  symptoms  had  persisted  for  a  long 
time,  even  many  years,  before  the  patients  came  under  observa- 
tion ;  but  taking  this  fact  into  account  it  may  be  stated  that  in 
more  than  half  the  cases  the  deformity  did  not  appear  until 
adolescence  and  that  at  least  three-fourths  of  the  patients  were 
beyond  the  period  of  early  childhood  when  the  ordinary  rhachitic 
distortions  of  the  limbs  are  most  common.  46  of  the  patients 
were  males,  26  were  females.  In  59  cases  the  deformity  was 
unilateral,  32  of  the  right  and  27  of  the  left  side;  in  13  it  was 
bilateral.  In  the  majority  of  the  cases  the  neck  of  the  femur 
was  distorted  in  a  direction  backward  and  downward ;  in  per- 
haps 10  either  directly  downward  or  downward  and  forward. 
,  Many  of  the  patients  were  observed  before  the  X-ray  was  avail- 
able for  diagnosis,  but  it  is  estimated  that  in  about  one-fourth  of 
the  adolescent  cases  the  distortion  was  greatest  in  the  vicinity 
of  the  head  of  the  bone  (epiphyseal  coxa  vara)  ;  in  the  others 
the  neck  of  the  femur  as  a  whole  was  involved  (cervical  coxa 
vara). 

Symptoms. — l.  Mechanical  Effects. — The  character  of  the 
symptoms  may  be  explained  by  a  description  of  the  distortion 
and  of  its  direct  effects  upon  the  function  of  the  joint.  When 
the  neck  of  the  femur  is  depressed,  for  example,  to  a  right  angle 
with  the  shaft,  the  trochanter  is  elevated  to  a  corresponding 
degree  above  JSTelaton's  line,  and  forms  a  noticeable  projection 
as  contrasted  with  the  normal  contour  (Fig.  382),  a  projection 
that  becomes  more  marked  when  the  thigh  is  flexed  and  adducted 


576 


OBTHOPEDIC  SUBGEEY. 


(Fig.  384).  In  most  instances  the  neck  is  twisted  backward 
following  the  line  of  least  resistance  in  its  downward  course  and 
as  the  head  of  the  bone  remains  in  the  acetabulum  the  trochan- 
ter is  thrown  forward  and  the  limb  is  rotated  outward.  The 
ability  to  abduct  the  thigh  is  dependent  upon  the  upward  incli- 
nation of  the  femoral  neck  (Fig.  389)  ;  when,  therefore,  this  in- 
clination is  diminished  the  range  of  abduction  is  lessened,  in 
part  by  the  greater  tension  that  is  exerted  upon  the  lower  por- 
tion of  the  capsule,  in  part  by  the  direct  contact  of  the  rim  of 

Fig.  382. 


Skiagram  of  coxa  vara  ;  deformity  most  marked  at  the  epiphyseal  junction. 
This  illustrates  the  mechanical  limitation  of  abduction  caused  by  the  deformity, 
and  the  compensatory  tilting  of  the  pelvis.     The  patient  is  shown  in  Fig.   385. 


the  acetabulum  with  the  neck  (Fig.  382) ,  and  in  part  by  the  adap- 
tive muscular  retractions  that  always  accompany  distortions  of 
this  character.  The  distortion  of  the  neck  in  a  direction  back- 
ward and  downward  changes  the  relation  of  the  acetabulum  to 
the  head  of  the  femur,  so  that  abduction  or  flexion  tends  to  dis- 
place it  from  its  socket.  Thus  the  range  of  abduction,  of  in- 
ward rotation,  and  of  flexion  is  limited,  while  that  of  adduction, 
outward  rotation,  and  extension  may  be  increased. 

There  is  actual  shortening  of  the  limb  dependent  upon  the 
upward  displacement  of  the  shaft  of  the  femur.     This  is  not 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     577 

often  more  than  an  inch  in  the  ordinary  type  of  adolescent  de- 
formity, but  the  apparent  shortening,  caused  by  the  adduction 
and  the  accommodative  upward  tilting  of  the  pelvis,  may  be 
extreme;  from  two  to  three  inches  is  not  uncommon  (Fig.  385). 

2.  Physical  Effects. — The  symjDtoms  of  coxa  vara  of  the  ordi- 
nary type  are  disco'm,fort,  aivkwardness,  limp,  shortening, 
atrophy,  limitation  of  motion,  deformity. 

Coxa  vara  is  a  more  disabling  deformity  than  genu  varum  or 
valgum,  and  its  attendant  symptoms  of  discomfort,  weakness, 
and  pain  are,  as  a  rule,  more  marked.  This  is  explained  by  the 
fact  that  in  coxa  vara  the  head  of  the  bone  is  in  part  displaced 
from  the  acetabulum  (Fig.  382),  while  in  the  deformities  at  the 
knee  the  joint  surfaces  remain  in  practically  normal  relation  to 
one  another. 

The  symptoms  of  unilateral  coxa  vara  vary  with  the  degree 
and  with  the  duration  of  the  deformity.  ,  The  patient  usually 
complains  of  sensations  of  stiifness  and  weakness,  referred  to 
the  thigh.  These  are  more  noticeable  on  changing  from  a  posi- 
tion of  rest  to  one  of  activity,  and  at  times,  particularly  after 
overexertion,  there  may  be  actual  pain.  By  far  the  most  im- 
portant symptom  and  the  one  that  almost  always  induces  the 
patient  to  seek  treatment  is  the  limp.  This  limp,  accompanied, 
as  it  usually  is,  by  outward  rotation  of  the  limb,  resembles  that 
caused  by  united  fracture  of  the  neck  of  the  femur.  On  phys- 
ical examination  the  actual  shortening,  explained  by  the  elevated 
and  prominent  trochanter  and  the  peculiar  unequal  limitation 
of  motion,  will  make  the  diagnosis  clear.  In  some  instances 
there  may  be  a  marked  degree  of  muscular  spasm,  and  there  is 
usually  moderate  atrophy  of  the  muscles  of  the  thigh. 

Bilateral  Coxa  Vara.. — If  the  deformity  is  bilateral  its  effect 
upon  the  gait  and  attitude  is  more  marked.  The  gait  is  ex- 
tremely awkward,  resembling  somewhat  that  of  knock-knees, 
for  the  limitation  of  abduction  forces  the  patient  to  sway  the 
body  from  side  to  side  in  order  that  the  knees  may  not  interfere ; 
and  if  the  deformity  is  extreme  the  limbs  may  be  crossed  over 
one  another,  so  that  locomotion  may  be  difficult.  In  the  ordinary 
form  of  bilateral  coxa  vara  the  femoral  neck  on  each  side  is 
displaced  backward  as  well  as  downward,  and  as  the  head  of  the 
femur  remains  in  the  acetabulum  the  shaft  is  thrown  forward, 
so  that  the  trochanter  is  nearer  the  anterior  superior  spine  than 
is  normal.  This  displacement  of  the  support  lessens  the  inclina- 
37 


578 


OBTHOPEDIC  SUEGEEY. 


tion  of  the  pelvis  and  consequently  the  normal  lumbar  lordosis. 

Bilateral  coxa  vara  is  not  infrequently  accompanied  by  other 

deformities,  as,  for  example,  knock-knee  or  flat-foot  (Fig.  386), 

and  it  is  usually  an  indirect  result  of  former  rhachitis  while  in 

unilateral   coxa  vara  injury    (fracture)    is  the   most  frequent 

cause. 

Fig.  383. 


Cross-section  of  the  pelvis  and  the  deformed  femur.  A  scheme  to  show  the 
effect  of  the  deformity  in  limiting  abduction  of  the  limb.  The  dotted  outline 
shows  the  normal  relation. 


Other  Varieties  of  Coxa  Vara, — Far  less  often  the  neck  of  the 
femur  may  be  depressed  directly  downward  or  even  downward 
and  forward.  In  the  latter  instance  the  effect  of  the  deformity 
upon  the  function  of  the  joint  is  somewhat  different  from  that 
of  the  ordinary  type.  Abduction  is  limited,  as  in  the  common 
form,  but  inward  rotation  replaces  outward  rotation,  and  ex- 
tension is  limited  in  place  of  flexion.  This  type  of  deformity 
is  almost  always  bilateral.  It  is  accompanied,  usually,  by  slight 
permanent  flexion  of  the  thighs;  thus  the  lumbar  lordosis  is 
exaggerated;  whereas,  in  the  ordinary  form  it  is  usually 
lessened. 

This  description  applies  to  the  ordinary  types  of  the  de- 
formity as  it  is  seen  in  later  childhood  and  in  adolescence.     It 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     579 

undoubtedly  occurs  in  early  life  as  one  of  the  rhachitic  de- 
formities but  it  is  masked  by  the  more  noticeable  distortions  of 
other  parts.  This  form  is  rarely  presented  for  treatment  but  it 
is  important  as  a  predisposing  cause  of  the  progressive  de- 
formity of  later  years.  In  some  cases  of  the  rhachitic  type, 
however,  the  deformity  may  cause  discomfort  and  awkwardness 
during  the  earlier  years,  the  disability  becoming  more  notice- 
able in  later  childhood,  indicating  a  continuity  of  symptoms. 

In  the  majority  of  cases  the  symptoms  begin  insidiously, 
in  the  unilateral  form  often  as  the  result  of  injury  or  over- 
exertion. (See  Partial  Epiphyseal  Separation.)  If  the  affec- 
tion begins  in  adolescence  and  is  untreated,  the  period  of  dis- 
comfort, during  which  the  depression  of  the  neck  may  be  as- 
sumed to  be  progressive,  is  from  two  to  four  years;  but  if  the 
deformity  appears  at  an  early  age,  the  symptoms,  though  re- 
mittent in  character,  may  continue  indefinitely.  When  the 
resistance  of  the  compressed  bone  becomes  sufficient  to  ensure 
stability  the  discomfort  ceases,  and  the  disability  becomes  less 
marked,  as  nature  accommodates  the  mechanism  to  the  new 
conditions. 

Diagnosis.^ — In  most  instances  diagnosis  may  be  easily  made, 
and  yet  coxa  vara  is  very  often  mistaken  for  hip  disease;  in 
fact,  we  are  indebted  to  this  mistake  for  most  of  the  specimens 
of  the  deformity  that  have  been  described.  The  essential  dif- 
ferences between  the  two  are  as  follows :  In  tuberculous  disease 
of  the  hip  the  motions  of  the  joint  are  limited  in  every  direc- 
tion by  reflex  muscular  spasm,  and,  as  a  rule,  other  evidences 
of  the  character  of  the  disease  are  apparent.  Coxa  vara  is  a 
simple  deformity;  reflex  muscular  spasm  is  absent,  except 
during  exacerbations  due  to  injury  or  overstrain,  and  move- 
ment is  not  limited  in  all  directions,  but  only  in  abduction, 
flexion,  and  inward  rotation  when  the  deformity  is  of  the 
ordinary  type.  Actual  shortening  is  a  late  symptom  of  hip 
disease,  while  it  is  present  from  the  very  onset  of  coxa  vara. 
It  is  a  shortening  explained  by  the  elevation  of  the  trochanter 
above  iN'elaton's  line,  while  such  elevation  in  hip  disease  is  a 
sign  of  destruction  either  of  the  head  of  the  bone  or  of  a  part 
of  the  acetabulum. 

The  deformity  in  young  subjects  might  be  readily  mistaken 
for  congenital  dislocation  of  the  hip,  particularly  of  the  an- 
terior variety,  but  this  would  be  excluded  by  the  history,  since 
coxa  vara  is  essentially  an  acquired  deformity.     The  diagnosis 


580 


ORTHOPEDIC  SUBGEBT. 


between  the  two  affections  may  be  easily  made  on  the  physical 
signs  alone.  In  congenital  dislocation,  if  the  thigh  be  flexed  and 
adducted  to  its  extreme  limit,  the  head  and  neck  of  the  dis- 


FiG.  384. 


Fig.  385. 


Coxa  vara,  showing  the  prominent  trochanter. 


Illustrating  the  tilting 
of  the  pelvis  and  the  ap- 
parent shortening  of  the 
limb  in  unilateral  coxa 
vara.  Actual  shortening, 
three-fourths  of  an  inch ; 
apparent  shortening,  two 
and  a  half  inches.  The  de- 
formity of  the  epiphyseal 
type  was  apparently  in- 
duced by  overexertion.  ( See 
skiagram,  Fig.   382.) 


placed  bone  can  be  outlined  beneath  the  distended  tissues  of 
the  buttock.  In  coxa  vara  nothing  but  the  prominent  tro- 
chanter can  be  made  out  on  similar  manipulation,  while  the 
abnormal  mobility,  characteristic  of  the  dislocation,  is  absent. 


CONGENITAL  DISLOCATION  OF  EIP  AND  COXA  VAEA.     581 

There  is,  however,  a  form  of  anterior  dislocation  in  which  the 
head  of  the  femnr  has  a  secure  support  beneath  the  anterior 
superior  spine  in  which  diagnosis  from  the  physical  signs  alone 
may  he  somewhat  more  difficult.  An  X-ray  picture  will  always 
make  the  distinction  clear,  however. 

Treatment. — If  the  deformity  were  discovered  in  the  early 
stage,  one  might  hope  to  check  its  progress  by  an  avoidance  of 
the  exciting  causes.     For  example,  long  standing  or  work  of 

Fig.  386. 


Double  coxa  vara  of  advanced  degree,  showing  the  involuntary  crossing 
of  the   limbs   in   flexion. 


any  kind  that  induces  the  familiar  symptoms  of  strain  should 
be  discontinued.  As  much  time  as  possible  should  be  spent  in 
the  open  air,  and  diet  and  proper  remedies  should  be  employed 
if  evidence  of  constitutional  weakness  or  rhachitis  is  present 
as  in  early  childhood. 

Locally,  massage  of  the  limbs  and  joints  and  forcible 
manipulation,  with  the  aim  of  overcoming  as  much  of  the  re- 
striction of  the  range  of  abduction  as  may  depend  upon  the 
secondary  changes  in  the  soft  parts,  should  be  employed,  rein- 
forced by  regular  gymnastic  exercises,  with  the  object  of  im- 
proving the  circulation,  upon  which  the  repair  of  the  weakened 
bone  depends. 


582 


ORTHOPEDIC  SUBGEBY. 


If  the  affection  is  •unilateral,  due,  for  example,  to  injury  with 
but  slight  deformity  a  perineal  crutch  (Fig.  271)  or,  if  the  cir- 
cumstances of  the  patient  permit,  one  of  the  convalescent  hip 
splints  that  permits  motion  at  the  knee,  may  be  used  (Fig.  273). 


Fig.  387. 


Fig.  388. 


Unilateral  coxa  vara,  showiag  the  effect 
of  sligHt  depression  of  the  neck  of  the 
left  femur  upon  the  attitude.  (See  Fig. 
388.) 

With  support  during  the  time  of 
greatest  strain — that  is,  when  con- 


The  patient,  Fig.  387,  eight 
months  after  cuneiform  oste- 
otomy. An  absolute  cure,  both  as 
regards  symptoms  and  deformity. 


tinuous  walking  or  standing  may  be 

acquired — combined    with    proper 

exercises   and  massage,   the   weak 

part  may  become  sufficiently  strong 

to  perform  its  function  in  a  year  or  more,  but  supervision  will 

be  necessary  for  a  much  longer  time. 

Operative  Treatment.. — As  a  rule  operative  correction  of  the 
deformity  is  indicated. 


CONGENITAL  DISLOCATION  OF  EIP  AND  COXA  VABA.     583 

Forcible  Abduction^ — In  certain  instances  particularly  those 
cases  in  adolescence  in  which  the  symptoms  have  advanced 
rapidly,  it  may  he  inferred  that  the  bony  structure  of  the 
affected  neck  is  congested  and  softened.  One  may  attempt, 
therefore,  to  restore  the  angle  by  forcibly  abducting  the  thigh, 
and  afterv^ards  rotating  it  inward  as  in  the  treatment  of  frac- 
ture or  epiphyseal  separation  with  which  this  form  is  closely 
allied.  (See  page  390.)  In  this  manoeuvre  the  head  is  fixed 
by  the  lower  portion  of  the  capsule,  and  the  deformed  neck  is 
forced  against  the  upper  border  of  the  acetabulum  as  illustrated 
in  the  diagrams  (Fig.  385).  If  the  normal  range  of  abduction 
and  inward  rotation  can  be  restored,  one  may  infer  that  the  de- 
formity has  been  corrected.  The  limb  should  then  be  fixed  by 
a  plaster  spica  bandage  in  this  attitude  of  extreme  abduction 
and  inward  rotation  until  consolidation  in  the  new  position  is 
apparently  complete.  A  short  spica  to  hold  the  limb  in  abduc- 
tion should  then  be  applied  and  continued  for  several  months. 

A  support  should  be  used  for  a  time,  and  the  usual  treatment 
by  massage  and  exercise  should  be  carried  out  until  voluntary 
and  passive  motion  is  relatively  free. 

Linear  Osteotomy. — The  most  efiicient  means  of  overcoming 
the  distortion  in  older  subjects  in  which  extreme  outward  rota- 
tion indicates  backward  distortion  of  the  neck  is  linear  oste- 
otomy of  the  shaft  of  the  femur  just  below  the  trochanter 
minor.  This  may  be  performed  by  the  subcutaneous  method, 
as  in  the  correction  of  the  deformity  of  hip  disease.  When  the 
bone  has  been  divided  the  shaft  is  rotated  inward  to  the  proper 
degree,  and  it  is  then  under  traction  abducted  to  the  normal 
limit;  in  this  attitude  a  plaster  spica  bandage  is  applied  reach- 
ing from  the  axilla  to  the  toes. 

If  the  deformity  is  bilateral  it  is  often  sufficient  to  operate 
on  the  limb  which  is  most  affected.  When  the  fracture  is  con- 
solidated, massage,  exercises,  and  manipulation  are  employed, 
as  has  been  described.  It  may  be  assumed  that  the  increased 
blood  supply  necessitated  by  the  repair  of  the  injury  will  affect 
favorably  the  weakened  bone  as  well. 

Cuneiform  Osteotomy.- — If  outward  rotation  is  not  marked  the 
deformity  should  be  remedied  by  removal  of  a  cuneiform  section 
of  bone  from  the  upper  extremity  of  the  shaft  at  the  level  of  the 
trochanter  minor  (Fig.  389).  In  childhood  the  neck  of  the  fe- 
mur is  short  and  the  strain  to  which  it  is  likely  to  be  subjected 
slight ;  thus  operative  treatment  may  be  indicated  as  a  prophy- 


584  OBTHOPEDIC  SrSGEEY. 

lactic  measure.  In  fact,  one  shonld  treat  this  deformity  at  the 
hip  on  the  same  principles  as  the  similar  distortions  at  the  kaee. 
Coxa  vara  cannot  be  rectified  by  mechanical  treatment;  there- 
fore, unless  it  is  directly  eontraindicated  operative  intervention 
should  be  advised. 

In  the  technique  of  this  procedure  there  are  several  points  of 
imjDortance.  First,  the  restriction  of  abduction,  of  ligamentous 
or  muscular  origin,  must  be  overcome  by  vigorous  stretching 
and  massage  of  the  shortened  tissues  before  the  operation  on  the 
bone.  An  incision  is  made  from  a  point  about  one  inch  below 
the  apex  of  the  trochanter  directly  downward  about  three 
inches  in  length.  The  bone  is  thoroughly  exposed  by  separat- 
ing the  periosteum  from  the  site  of  operation.  The  base  of 
the  wedge  should  be  about  three-quarters  of  an  inch  in  breadth, 
directly  opposite  the  trochanter  minor ;  the  upper  section  should 
be  practically  at  a  right  angle  vtdth  the  shaft,  the  lower  being 
more  oblique  (Fig.  389,  2).  The  situation  and  size  of  the 
wedge-shaped  resection  necessary  to  restore  the  normal  angle  of 
the  neck  may  be  determined  by  making  a  paper  model  from 
an  X-ray  picture.  The  cortical  substance  on  the  inner  aspect 
of  the  bone  should  not  be  divided,  but,  reinforced  by  the 
cartilaginous  trochanter  minor,  should  serve  as  a  hinge  on 
which  the  shaft  of  the  femur  is  gently  forced  outward,  until 
the  opening  is  closed  by  the  apposition  of  the  fragments  after 
the  upj)er  segment  has  been  fixed  by  contact  with  the  margin  of 
the  acetabulum  (Fig.  389,  3)  ;  thus  the  continuity  of  the  bone 
is  preserved.  The  limb  is  then  fixed  in  the  attitude  of  normal 
abduction  by  means  of  a  plaster  spica  bandage,  which  should 
include  the  foot  also,  for  about  eight  weeks,  or  until  the  union 
is  firm.  "When  the  limb  is  brought  to  the  line  of  the  body  the 
neck  of  the  femur  is  restored  to  its  proper  position  (Fig. 
389,  4).  This  mechanical  method  of  apposing  the  fragments  is 
absolutely  effective.  This  method  in  which  the  exact  section  of 
bone  required  to  correct  the  deformity  may  be  determined  by 
an  X-ray  picture  and  in  which  the  continuity  of  the  bone  is 
preserved  has  a  manifest  advantage  over  a  simple  osteotomy  in 
which  there  is  danger  of  displacement  of  the  fragments.  In 
ordinary  cases  of  this  class,  according  to  the  writer's  experience, 
the  cure  is  absolute,  both  as  to  symptoms  and  to  function. 

The  opi^ortunity  for  treatment  of  coxa  vara  in  earliest  child- 
hood is  rarely  offered.  It  is  usually  the  direct  result  of  rha- 
chitis,  and  it  is  probably  always  accompanied  by  other  rhachitic 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VAEA.     585 

distortions.  It  would  be  well,  therefore,  to  examiiie  the  hip- 
joints  of  rhachitic  children,  especially  those  who  present  the 
deformity  of  genu  valgum  with  reference  to  this  distortion. 

FRACTURE  OF  THE  NECK  OF  THE  FEMUR. 

"  Traumatic  Coxa  Vara." — Fracture  of  the  neck  of  the  femur 
in  childhood,  although  until  recently  unrecognized,  is  by  no 
means  uncommon.  More  than  50  cases  have  come  under  the 
writer's  observation  since  1890  when  he  first  called  attention  to 


Fig.  389. 


1.  The  normal  femnr.  2.  Depression  of  the  neck  of  the  femur — coxa  vara. 
A.  A  wedge  of  bone  has  been  removed.  3.  Abduction  of  the  limb  first  Axes  the 
upper  segment  by  contact  with  the  rim  of  the  acetabulum,  then  closes  the  opening 
in  the  bone.  4.  Replacement  of  the  limb  after  union  is  completed  elevates  the 
neck  to  its  former  position. 

the  subject.  It  is  seen  in  two  forms.  In  the  first  the  fracture  is 
of  the  neck  and  it  usually  follows  direct  violence.  In  the  second 
the  fracture  is  at  the  epiphyseal  junction  with  the  head.  This 
form  is  practically  limited  to  adolescence. 

SIMPLE  FRACTURE. 

Fracture  of  the  neck  of  the  femur  in  childhood  differs  some- 
what in  its  symptoms  and  in  its  effects  from  that  in  later  life. 


586 


ORTHOPEDIC  SUBGEBY. 


Although  it  may  he  complete,  it  is  often  what  may  be  termed 
of  the  "green  stick"  variety.  Thus,  the  immediate  effects  of 
the  injury  are  far  usually  less  disabling,  and  the  patient  is 
often  able  to  walk  about  within  a  few  days  after  the  accident. 
During  the  period  of  repair  the  limp  and  attendant  discomfort 
are  usually  mistaken  for  symptoms  of  hip  disease  and  at  a 
later  time  it  is  classed  as  coxa  vara. 

Fig.  390. 


1.  Fracture  of  the  neck  of  the  femur.  2.  Restoration  of  the  normal  angle 
by  forcible  abduction.  3.  The  limb  in  normal  position.  4,  5,  and  6  illustrate 
separation  of  the  epiphysis  of  the  head  of  the  femur  treated  by  the  same  method. 


Diagnosis.^ — The  diagnosis  is  not  difficult.  There  is  a  history 
of  injury,  usually  a  fall  from  a  height  which  confined  the 
patient  to  the  bed  for  several  days  or  weeks.  On  physical,  ex- 
amination shortening  of  half  an  inch  to  an  inch  is  found,  ex- 
plained by  the  corresponding  elevation  of  the  trochanter. 
Motion  in  the  joint  is  more  or  less  restrained  by  voluntary  and 
involuntary  contraction  of  the  muscles,  but  this  restriction  is 
much  more  marked  in  flexion,  abduction,  and  inward  rotation 
than  in  other  directions ;  a  limitation  explained  by  the  nature 
of  the  displacement,  the  neck  of  the  bone  having  been  forced 
downward  and  backward. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VAEA.    587 


Fig.  391. 


The  immediate  effect  of  the  injury  is,  as  has  been  stated, 
less  marked  than  in  the  adult,  but  the  deformity  often  tends  to 
increase  in  later  years,  because  the  right-angled  relation  of  the 
neck  to  the  shaft  exposes  it  to  greater  strain.  In  a  number  of 
the  patients  examined  several  years  after  the  injury  there  was 
an  increase  of  the  actual  shortening  combined  with  permanent 
adduction.  At  this  time  the  deformity  could  not  have  been 
distinguished,  except  for  the  history, 
from  the  ordinary  coxa  vara  of  a  rather 
extreme  degree. 

Treatment, — If  the  diagnosis  is  made 
immediately  or  before  consolidation  is 
complete,  one  should  attempt  to  replace 
the  neck  in  its  proper  relation  with  the 
shaft  in  order  to  restore  normal  func- 
tion and  to  prevent  subsequent  disability. 
The  patient  having  been  anaesthetized, 
the  limb  under  manual  traction,  should 
by  gentle  force  be  placed  in  the  attitude 
of  full  abduction  and  extension,  thus 
utilizing  the  fulcrum  of  the  upper  bor- 
der of  the  acetabulum  to  restore  the 
normal  angle  of  the  neck.  In  this  posi- 
tion a  plaster  bandage,  reaching  from 
the  axilla  to  the  toes,  should  be  applied 
(Fig.  390). 

After  consolidation  of  the  fracture  a 
Lorenz  spica  may  be  used  for  several 
months  or  until  complete  repair  has 
taken  place.  Massage  and  passive 
movements,  if  limitation  of  motion  per- 
sists, should  restore  function  if  the  de- 
formity has  been  overcome. 

After  consolidation  the  untreated 
fracture  is  practically  a  form  of  coxa  umb. 
vara.  In  such  cases  the  neck  of  the  femur  should  be  replaced 
in  its  normal  position  by  the  removal  of  a  sufficient  wedge  of 
bone  from  the  base  of  the  trochanter  as  described  under  the 
treatment  of  simple  coxa  vara  (Fig.  389). 

Epiphyseal  Fracture. — As  has  been  stated  in  early  life  the  frac- 
ture is  usually  at  about  the  centre  of  the  neck,  which  in  child- 
hood is  but  little  more  than  an  inch  in  length.    In  later  years  the 


Epiphyseal  fracture  of  the 
neck  of  the  right  femur,  il- 
lustrating the  type  of  pa- 
tient especially  predisposed 
to  such  injury  and  the  char- 
acteristic    attitude     of     the 


588  OETHOPEDIC  SUBGEBY. 

head  of  the  femur  may  be  partially  or  completely  separated  at  or 
near  the  epiphyseal  line.  This  disjunction  is  more  likely  to  occur 
in  adolescence  and  particularly  in  fat,  overgrown  or  weak  sub- 
jects, although  it  may  occur  in  perfectly  healthy  individuals. 
Thus  sudden  disability,  following  slight  injury,  in  an  adoles- 
cent who  has  complained  of  discomfort  and  limp  for  some  time 
before,  should  suggest  this  accident,  the  previous  symptoms 
being  explained  by  slight  displacement  or  weakening  of  the 
epiphyseal  junction.  In  other  instances  the  separation  may  be 
complete,  the  direct  result  of  violence  (Fig.  391). 

Treatment. — In  characteristic  cases  the  limb  is  adducted, 
often  extended,  rotated  outward  to  an  extreme  degree,  and 
often  practically  fixed,  by  muscular  spasm.  If  the  separation 
is  complete  a  prominence  may  be  felt  below  and  to  the  inner 
side  of  anterior  superior  spine  representing  the  inner  extremity 
of  the  neck  which  lies  above  and  in  front  of  the  head.  If  the 
fracture  is  recent  it  may  be  possible  to  reduce  the  deformity 
under  anaesthesia  by  flexion,  and  outward  rotation  followed  by 
traction,  and  abduction  or  in  recent  cases  by  direct  abduction. 
In  many  instances,  however,  the  injury  is  of  long  standing  and 
the  fragments  are  so  interlocked  and  adherent  that  they  can  not 
be  disengaged.  In  such  cases  direct  operation  is  indicated.  An 
incision  about  5  inches  in  length  is  made  downward  from  the 
anterior  superior  spine  along  the  outer  or  inner  side  of  the  tensor 
vaginae  femoris  muscle.  The  joint  is  opened  and  the  surface 
of  the  neck  is  at  once  exposed  completely  concealing  the  head. 
By  extreme  outward  rotation  of  the  limb  this  may  be  brought 
into  view  and  a  thin  chisel  is  inserted  between  the  two.  The 
fragments  are  then  forced  apart  and  by  traction  and  internal 
rotation  the  neck  is  gradually  brought  into  its  proper  relation. 
In  many  instances,  however,  a  thin  section  of  bone  must  be 
removed  from  the  extremity  of  the  neck  to  permit  reduction 
without  violence.  The  wound  is  closed  and  a  long  spica  plaster 
is  applied  to  hold  the  limb  in  inward  rotation  and  abduction 
until  union  is  firm.  Active  and  passive  exercises  should  be 
employed  until  function  is  restored.-^ 

As  has  been  suggested,  slight  injury,  under  favoring  condi- 
tions, may  rupture  the  periosteum  and  the  cortical  substance  at 
the  junction  of  the  epiphysis  and  the  neck  of  the  femur,  and 
under  the  strain  of  use  the  head  of  the  bone  may  be  slowly 

^  This  class  of  cases  is  described  at  lengtli  in  a  recent  paper.  AVhitman, 
N.  Y.  Medical  Keeord,  January,  1909. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VAEA.    589 

depressed,  the  final  result  being  the  epiphyseal  type  of  coxa 
vara  that  has  been  described,  in  which  repair  and  deformity  are 
coincident.  The  symptoms  of  this  variety,  which  is  practically 
limited  to  adolescence,  resemble  those  of  ordinary  coxa  vara, 
except  that  they  are  more  marked  and  more  disabling. 

Six  cases  of  complete  and  unnnited  fractnre  of  the  neck  of  the 
femur  in  early  life  have  come  under  my  observation  illustrat- 
ing the  fact  that  non-union  after  this  injury  is  not  to  be  ac- 
counted for  by  deficiency  of  blood  supply  but  by  separation  of 
the  fragments.  This  indicates  that  if  with  adult  class  deform- 
ity were  reduced  and  the  injured  part  supported  repair  and 
restoration  of  function  might  result. 

Fracture  of  the  Neck  of  the  Femur  in  Adult  Life. — The 
treatment  by  abduction  and  fixation  recommended  for  fracture 
of  the  neck  of  the  femur  or  epiphyseal  separation  in  childhood, 
with  the  aim  of  restoring  symmetry,  should  be  applied  therefore 
in  all  cases  that  are  amenable  to  treatment.  The  so-called  im- 
pacted fracture  if  caused  by  indirect  violence  is  in  most  in- 
stances incomplete  rather  than  impacted  in  the  sense  of  actual 
penetration  of  one  fragment  into  the  other.  If  the  deformity 
is  not  corrected  functional  disability  is  inevitable. 

The  patient  having  been  anaesthetized  is  placed  upon  a  box 
of  sufficient  size,  about  seven  inches  in  height,  the  pelvis  resting 
on  a  sacral  support  and  the  extended  limbs  held  by  assistants. 
That  on  the  sound  side  is  then  abducted  to  the  normal  limit  to 
demonstrate  the  range  and  to  fix  the  pelvis.  That  on  the  in- 
jured side  is  then  under  traction  slowly  abducted,  the  surgeon 
supporting  the  joint  with  his  hands  and  pressing  the  trochanter 
gently  downward.  The  limitation  of  abduction,  caused  by 
contact  of  the  deformed  neck  with  the  upper  border  of  the  ace- 
tabulum, is  recognized,  but  it  is  easily  overcome.  When  the 
limit  of  normal  abduction  is  reached  it  may  be  inferred  that  the 
proper  relation  between  the  neck  and  shaft  of  the  femur  has  been 
restored.  The  outward  rotation  is  then  corrected  and  the  limb  is 
securely  fixed  in  this  attitude  by  a  long  plaster  spica  until  repair 
is  sufficiently  advanced  (Fig.  394).  It  may  be  noted  that  this 
method  of  reducing  the  deformity  by  abduction  followed  by  the 
immediate  application  of  support,  hardly  corresponds  to  what 
is  known  as  the  "breaking  up  of  an  impaction."  Far  from 
endangering  union  it  should  favor  it  by  actually  apposing  the 
fractured  surface. 

If  the  fracture  is  complete  the  same  treatment  is  adopted 


590 


OETHOPEDIC  SUBGESY. 
Fig.  392. 


The  abduction  treatment  of  fracture  of  the  neck  of  the  right  femur,  illus- 
trating the  reduction  of  the  deformity  by  direct  traction  and  abduction.  The 
operator  supports  the  joint.  The  left  limb  is  abducted  to  indicate  the  normal 
range,  which  varies  in  different  subjects,  and  to  prevent  tilting  of  the  pelvis. 


A.  Complete  fracture  of  the  neck  of  the  femur,  illustrating  the  influence  of 
the  muscles  in  increasing  the  displacement.  B.  Complete  fracture,  after  reduc- 
tion and  fixation  in  the  position  of  abduction,  illustrating  the  security  assured 
by  the  direct  contact  of  the  trochanter  with  the  side  of  the  pelvis ;  also  the 
tension  on  the  capsule  and  the  removal  of  the  deforming  influence  of  the  muscles. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VABA.    591 

with  the  following  modification.  The  patient  lying  in  the  posi- 
tion described  with  the  sound  limb  held  in  abduction  the  dis- 
abled member  is  first  flexed  to  disengage  folds  of  capsule  that 
may  have  fallen  between  the  fragments.  It  is  then  extended 
and  rotated  to  the  normal  attitude  and  under  traction  and 
counter-traction  the  shortening  is  completely  overcome,  as  demon- 
strated by  m'easurement.  The  limb  is  then  slowly  abducted 
by  the  assistant  while  the  surgeon  supporting  the  joint  pushes 
the  thigh  upward  from  beneath  to  force  the  two  fragments 

Fig.  394. 


The  long  spica  as  applied  for  the  treatment  of  fracture  of  the  neck  of  the  femur 
In   the   adult   at   an   angle   of   abduction   of   45   degrees. 


against  the  anterior  part  of  the  capsule.  When  the  limit  of 
abduction  has  been  reached  the  capsule  will  be  tense,  thus 
directing  the  fragments  toward  one  another,  the  trochanter 
will  be  apposed  to  the  side"  of  the  pelvis,  thus  preventing  up- 
ward displacement  and  the  muscles  whose  contraction  favors 
deformity,  will  be  completely  relaxed.  A  plaster  spica  is  then 
applied,  as  in  the  preceding  instance.  In  the  treatment  of 
elderly  subjects  it  is  well  to  raise  the  head  of  the  bed  from  1-2. 
feet  to  lessen  the  danger  of  hypostatic  congestion  of  the  lungs 
and  to  increase  the  blood  supply  at  the  seat  of  injury.  Repair 
must  tie  slow  and  weight  must  not  be  borne  for  many  months. 


592  OPiTHOPEDIC  SUBGEEY. 

lu  the  after-treatment  the  support  of  a  modified  hip  splint  (Fig. 
257)  is  desirable,  and  functional  recovery  will  be  hastened  bv 
massage  and  by  apjDropriate  active  and  passive  exercises  of 
which  by  far  the  most  important  is  to  draw  the  limb  at  intervals 
to  the  comj)lete  limit  of  abduction. 

One  often  encounters  cases  in  which  the  disability  persists 
after  fracture  of  the  neck  of  the  femur  even  though  union  has 
taken  place.  This  disability  is  due  in  great  part  to  adduction 
deformity  which  is  induced  by  depression  of  the  neck  of  the 
femur  and  by  fixation  of  the  limb  in  the  line  of  the  body  as  in 
ordinary  methods  of  treatment.  Such  deformity  may  be,  in 
many  instances,  reduced  by  moderate  force.  The  limb  is  then 
fixed  for  a  time  in  abduction.  If,  as  is  often  the  case,  the 
fracture  has  failed  to  unite  and  the  open  operation  is  imprac- 
ticable the  upper  extremity  of  the  femur  may  be  forced  for- 
ward beneath  the  anterior  superior  spine  and  the  limb  may  be 
fixed  in  an  attitude  of  abduction  and  extension  by  a  short  spica, 
as  originally  suggested  by  Lorenz.-^ 

Open  Operation, — In  those  cases  of  ununited  fracture  in 
young  or  middle  aged  subjects  in  which  non-union  may  be  ex- 
plained by  failure  to  appose  the  fragments  the  open  operation 
may  be  indicated. 

The  shortening  having  been  reduced  by  preliminary  traction 
in  bed  an  incision  is  made  from  the  anterior  superior  spine 
downward  and  outward  to  the  base  of  the  trochanter,  between 
the  tensor  vaginse  femoris  and  gluteus  medius  muscles.  The 
joint  is  opened  in  the.  line  of  the  neck  and  the  two  surfaces  of 
bone  are  laid  bare  and  properly  adapted  to  one  another.  A 
long  strong  bone  drill  is  then  thrust  through  the  skin,  the 
trochanter,  and  the  neck  until  its  point  emerges.  The  fractured 
surface  of  the  neck  is  then  apposed  to  the  head  and  the  drill 
is  driven  deeply  into  its  substance.  The  wound  is  closed  and 
the  limb  is  fixed  in  an  attitude  of  extension  and  abduction  by 
a  plaster  spica.     The  after-treatment  is  similar  to  that  for  non- 

oj)erative  cases. 

COXA  VALGA. 

Coxa  valga  is  a  term  used  to  signify  an  abnormal  elevation 
of  the  neck  of  the  femur  in  its  relation  to  the  shaft,  in  contrast 

^  The  author 's  method  of  treating  fracture  of  the  neck  of  the  femur  in 
the  adult  is  described  in  detail  in  the  Amer.  Jour,  of  Med.  Sei.,  July,  1905. 
The  Medical  Eecord,  March  19,  1904.  The  Therapeutic  Gazette,  May,  1906. 
N.  Y.  State  J.  Med.,  May,  1909.  Zeits.  f.  Orth.  Chir.,  1909,  B.  24.  H.  1 
and  2.  The  abduction  treatment  in  the  treatment  of  children  was  first  de- 
scribed in  1897.      Annals  of  Surgery,  June. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  FAEA.    593 

to  coxa  vara,  an  abnormal  depression.  It  is  usually  congenital. 
It  is  sometimes  observed  in  limbs  which  have  never  supported 
weight  and  is  a  possible  result  of  injury  also.  Its  symptoms 
are  an  awkward  gait,  the  limb  being  rotated  outward  and  ab- 
ducted. The  deformity  is  very  uncommon  and  is  of  slight 
importance.  Sixteen  cases  have  been  collected  by  Maullaire 
and  Olivier.-^ 

Treatment  should  be  directed  to  overcoming  the  limitation 
of  adduction.  This  may  be  manipulative  or  by  force  under 
anaesthesia  followed  by  retention  in  the  attitude  of  adduction. 
In  rare  instances  osteotomy  may  be  indicated.^ 

^  Archiv  Gen.  de  Chir.,  B.  4,  15,  1. 

^  Young,  Univ.  Pa.  Bui.,  January,  1907. 


38 


CHAPTEE   XVI. 

DEFORMITIES  OF  THE  BONES  OF  THE  LOWER  EXTREMITY. 

Of  the  distortions  of  tlie  lower  extremity  bow-leg  and  knock- 
knee  are  bj  far  the  most  common,  comprising  about  15  per 
cent,  of  the  total  cases  in  orthopedic  clinics.  Of  the  two,  bow- 
leg is  the  more  frequent  in  all  tables  of  statistics,  and  it  is 
probable  that  the  proportion  of  bow-leg  to  knock-knee  is  much 
larger  than  would  appear  from  the  hospital  records ;  for  genu 
valgum  is  generally  recognized  as  a  serious  deformity,  while 
bow-leg  is  known  to  be  of  little  consequence  except  from  the 
aesthetic  standpoint,  so  that  its  rectiiication  is  more  often  trusted 
to  the  power  of  nature. 

Both  deformities  appear  to  be  more  common  in  male  than  in 
female  children — a  fact  explained,  perhaps,  by  the  gTeater 
weight  and  the  greater  susceptibility  of  the  former.  But  here, 
again,  statistics  may  be  influenced  somewhat  by  the  fact  that 
bow-leg  is  considered  to  be  of  more  consequence  to  the  boy  than 
to  the  girl,  because  of  the  concealment  that  the  skirts  will 
ensure  if  the  distortion  is  not  outgrown  in  childhood. 

Statistics.- — The  relative  frequency  of  the  two  deformities 
may  be  indicated  by  the  statistics  of  the  Hospital  for  Ruptured 
and  Crippled  for  a  period  of  15  years,  1899-1904.  During 
this  time  8760  cases  were  recorded,  5741  cases  of  bow-leg  (65.5 
per  cent.),  3019  of  knock-knee  (34.5  per  cent.).  Of  the  5741 
cases  of  bow-leg  3401  were  in  males  (59  per  cent.)  and  2340 
were  in  females  (41  per  cent.).  The  3019  cases  of  knock-knee 
were  more  evenly  divided  between  the  sexes,  1601  being  in 
males  (50.04  per  cent.)  and  1409  in  females  (49.06  per  cent.). 

It  will  be  noted  that  94  of  the  cases  of  knock-knee  were  in 
patients  over  fourteen  years  of  age,  as  compared  with  78  cases 
of  adolescent  or  adult  bow-leg.  The  writer's  personal  expe- 
rience in  the  clinic  enables  him  to  state  that  a  large  proportion 
of  the  cases  of  genu  valgum  actually  developed  or  increased  to 
an  extent  demanding  treatment  during  adolescence,  while  most 
of  the  cases  of  bow-leg  deformity  in  patients  more  than  fourteen 
years  of  age  had  existed  since  early  childhood  or  were  the  result 
of  injury  or  disease. 

594 


DEFOEMITIES  OF  BONES  OF  LOWEB  EXTREMITY.        595 

The  Etiology  of  Genu  Valgum,  Genu  Varum,  and  of  Other 
Distortions  of  the  Bones  of  the  Lower  Extremity. — The  com- 
mon predisposing  cause  of  simple  deformities  and  disabilities 
of  the  lower  extremities — in  other  words,  those  not  caused  by 
local  disease — is  the  erect  posture,  when  for  any  reason  the 
bones  and  the  joints  are  unequal  to  the  strain  of  locomotion 
and  to  the  task  of  sustaining  the  weight  of  the  body. 

Time  of  Onset, — At  two  periods  of  life  the  deformities  under 
consideration  most  often  develop.  The  first  is  in  early  child- 
hood, when  the  upright  posture  is  first  assumed;  the  second  is 
in  adolescence,  when  the  rapid  growth  and  other  changes  inci- 
dent-to  this  period  may  lessen  the  stability  of  the  supporting 
structures,  and  when  the  strain  of  laborious  occupation  may  be 
added  to  that  of  the  increasing  weight  of  the  body. 

The  deformities  of  adolescence  are,  however,  relatively  in- 
significant in  number  compared  with  those  of  early  childhood, 
for  in  childhood  inherited  weakness  or  weakness  that  is  the 
direct  result  of  malnutrition  at  once  develops  into  deformity 
under  the  strain  of  standing  and  walking.  Thus,  as  a  rule,  the 
deformities  under  consideration  first  attract  attention  soon 
after  the  child  begins  to  walk.  If  the  deformities  are  severe  the 
body  usually  presents  the  evidences  of  general  rhachitis ;  in 
other  instances  the  distortion  of  the  legs  is  almost  the  only  sign 
of  its  presence,  and  in  a  certain  number  there  may  be  no  evidence 
whatever  of  malnutrition  or  disease. 

Predisposition  to  Deformity. — It  is  not  always  easy  to  explain 
why  weak  legs  bend  in  one  way  rather  than  in  another.  In 
many  instances  it  may  be  assumed  that  a  slight  degree  of  de- 
formity is  present  before  the  child  begins  to  walk.  Tor  ex- 
ample, a  slight  outward  bowing  of  the  legs  is  not  uncommon  in 
early  infancy,  and  the  use  of  heavy  diapers  might  favor  an 
increase  of  the  distortion.  Knock-knee  may  be  induced,  ap- 
parently, by  holding  the  infant  on  the  arm  with  the  knees 
pressed  against  the  chest,  and  certain  cases  of  knock-knee  and 
bow-leg  combined  appear  to  be  caused  directly  by  this  manner 
of  carrying  the  infant  habitually  upon  one  arm. 

The  legs  of  rhachitic  children  who  may  have  never  walked  are 
often  somewhat  distorted  and  in  many  instances  this  may  be 
explained  by  the  habitual  postures  (Fig.  395). 

A  moderate  degree  of  bow-leg  is  not  infrequently  seen  in 
vigorous  infants  who  stand  and  walk  at  an  early  age.  Aside 
from  the  determining  curve  in  the  bone  that  may  be  present 


596 


OETHOPEDIC  SUBGEBY. 


before  tbe  child  begins  to  walk,  this  predisposition  toward  bow- 
leg may  be  explained,  perhaps,  by  the  fact  that  young  infants, 
often  separate  the  feet  widely  in  walking,  and  the  swaying  of 
the  body  from  side  to  side  may  tend  to  bend  the  legs  outward. 
In  weaker  or  less  vigorous  children  a  slight  degree  of  knock- 
knee  is  not  uncommon,  induced  more  directly  by  weakness  or 


Fig.  395. 


Habitual  posture  as  a  factor  in  tbe  etiology  of  rbacbitic  bow-leg. 

inactivity  of  the  muscles,  as  a  result  of  which  the  child  stands 
with  the  knees  somewhat  flexed  and  pressed  together,  while  the 
feet  are  separated  and  everted,  an  exaggeration  of  the  so-called 
attitude  of  rest. 

Bow-leg  is  not  uncommon  in  adult  life,  and  it  is  popularly 
associated  with  strength  and  activity.  Undoubtedly  the  atti- 
tudes of  activity  would  tend  to  induce  bow  leg  rather  than 
knock-knee,  so  that  this  tradition  may  have  a  foundation  of 
truth.  It  is  said  to  be  common  among  those  who  ride  con- 
stantly, and  it  may  be  a  direct  result  of  injury  or  disease  of  the 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.        597 

knee-joint,  but  it  may  be  stated  that  well-marked  bow-leg  in  an 
adult  has  almost  always  existed  since  childhood.  This  state- 
ment cannot  be  made  of  genu  valgum,  since  it  may  develop 
or  increase  during  adolescence  or  even  in  adult  life.  The  pre- 
disposing cause  is  weakness  or  overstrain,  and,  as  has  been 
stated,  in  the  popular  mind  the  deformity  is  characteristic  of 
weakness. 

The  Attitude  of  Rest^ — Genu  valgum  is  an  exaggeration  of 
what  is  known  as  the  attitude  of  rest  or  relaxation,  in  which  the 
weight  of  the  body  is  thrown  in  great  part  upon  the  ligaments 
of  the  three  joints  of  the  lower  extremity.  In  the  attitude  of 
rest  the  pelvis  is  tilted  forward,  the  femora  are  rotated  inward 
upon  the  tibiae,  and  the  feet  are  separated  and  everted,  so  that 
the  greatest  strain  falls  uj)on  the  inner  side  of  the  knees  and  of 
the  feet.  Thus,  what  is  known  as  flat-foot  is  in  childhood  often 
combined  with  knock-knee.  Knock-knee  may  cause  flat-foot,  but 
more  often  the  flat-foot  may  induce  knock-knee,  or  both  may  be 
the  effect  of  the  same  general  cause.  Genu  valgum,  in  the  slighter 
degree  at  least,  may  be  induced  directly  by  improper  attitudes ; 
but  the  attitudes  are,  as  a  rule,  the  result  of  overwork  to  which 
the  mechanism  is  subjected ;  thus  the  knock-knee  of  adolescence 
is  so  common  among  the  bakers  of  Vienna  that  "  baker's  knee  " 
is  there  synonymous  with  genu  valgum. 

Genu  valgum  may  be  secondary  to  distortion  elsewhere.  For 
example,  compensatory  knock-knee  is  usually  combined  with 
fixed  adduction  of  the  thigh;  it  may  be  the  result  of  the  in- 
activity necessitated  by  the  treatment  of  hip  disease ;  it  may  be 
a  direct  result  of  injury,  and  it  is  sometimes  an  accompaniment 
of  .osteomyelitis  or  osteoperiostitis  of  the  tibia,  which,  causes  an 
overgrowth  and  abnormal  lengthening  of  the  leg.  These  are, 
however,  exceptional  cases  that  should  not  be  classed  with  the 
ordinary  deformity. 

The  Outgrowth  of  Deformity, — In  considering  the  treatment  of 
the  simple  static  deformities  of  the  lower  extremity,  which  are 
usually  the  result  of  a  temporary  weakness  of  structure,  one 
must  first  answer  the  question,  "Will  not  the  child  outgrow 
it  ? "  This  belief  in  the  spontaneous  cure  of  deformity  is  very 
strong,  not  only  among  the  laity,  but  among  physicians  as  well ; 
and  it  rests  upon  the  common  observation  that  crooked  legs 
become  straight,  or  at  least  less  deformed,  with  the  growth  of 
the  child.  In  fact,  if  one  were  to  judge  from  the  general  ob- 
servation of  the  effect  of  growth  upon  the  deformities  of  this 


598  OBTHOPEDIC  SUBGEBY. 

class,  or  'even  from  the  tracings  of  the  legs  of  rhachitic  children 
taken  from  year  to  year,  one  might  conclude  that  all  deform- 
ities of  this  class  might  be  safely  left  to  themselves.  As  an 
illustration  of  positive  evidence  on  the  subject,  the  observations 
of  Kamps""-  on  32  cases  of  rhachitic  distortion  of  the  lower  ex- 
tremity may  be  cited.  Four  and  one-half  years  after  the  cases 
were  first  seen  and  recorded  examination  showed  that  Y5  per 
cent,  were  cured,  15.3  per  cent,  improved,  while  9.T  per  cent, 
were  unimproved.  His  conclusions  are  that  such  deformities 
do  not,  as  a  rule,  require  special  treatment  in  early  childhood, 
but  that  after  the  age  of  six  years  the  prognosis  for  spontaneous 
cure  is  unfavorable, 

Veit^  photographed  a  number  of  rhachitic  children  seen  in 
the  surgical  clinic  of  the  University  of  Berlin,  and  after  a  lapse 
of  two  or  three  years  made  another  series  of  photographs  of  the 
same  patients,  who  had  meanwhile  received  no  treatment.  His 
conclusions  are  similar  to  those  of  Kamps,  namely,  that  surgical 
treatment  is  not  required  for  deformity  of  this  character  in 
children  less  than  six  years  of  age.  In  two  classes  of  cases,^ 
however,  the  prognosis  for  spontaneous  cure  is  not  favorable, 
those  in  which  the  growth  has  been  checked  by  the  rhachitic 
process,  and  in  certain  cases  of  extreme  bow-leg,  "  0 "  legs 
(Fig.   396). 

The  rectifying  force  of  nature  acts  in  two  ways.  Assuming 
that  the  deformity  reached  its  limit  during  the  period  of  orig- 
inal weakness,  it  must,  of  course,  become  relatively  less  as  the 
body  increases  in  length  and  size.  In  fact,  the  outgrowth  of 
deformity  has  a  direct  relation  to  the  rapidity  of  growth  during 
the  early  years  of  childhood.  It  must  be  borne  in  mind  also 
that  not  infrequently  rhachitic  bones  are  bent  in  two  or  more 
directions  so  that  knock-knee  and  bow-leg  may  be  combined  in 
the  same  person.  One  may,  therefore,  outgrow  the  bow-leg 
while  the  knock-knee  persists  or  in  time  becomes  less  noticeable. 
The  second  manifestation  of  the  power  of  nature  is  more  posi- 
tive. It  may  be  assumed  that  when  the  deformity  is  progressive 
all  the  tissues  are  affected  by  the  weakness;  consequently  the 
attitudes  of  the  child  are  those  that  can  be  most  easily  assumed 
under  the  abnormal  conditions.  But  when  the  primary  cause 
of  the  weakness,  in  most  instances  rhachitis,  is  no  longer  opera- 
tive, the  muscles  take  on  new  activity  and  vigor,  and  the  actions 

^  Beitrage  zur  klin.  Chir.,  B.  xiv.,  H.  1. 
-  Archiv  f .  Chir.,  B.  1,  S.  130. 


DEFOEMITIES  OF  BONES  OF  LOWEB  EXTEEMITY.        599 


and  attitudes,  in  spite  of  the  deformity,  become  approximately 
normal.  Then,  according  to  Wolff's  law  of  transformation,  the 
internal  structure  of  the-  affected  bones  begins  to  change  to  ac- 
commodate itself  to  the  new  conditions  of  weight  and  strain 
induced  by  the  change  in  action  and  attitude ;  and  to  this  rear- 
rangement of  the  internal  structure  the  external  shape  of  the 
bones  must  conform  in  a  gradual  growth  toward  the  normal 
contour. 

On  this  theory  it  is  easily  explained  how  the  natural  outdoor 
life  of  the  country  has  long  been  celebrated  as  an  effective  treat- 
ment for  this  class  of  deformity.  But  it  by  no  means  follows 
that  deformity  is  always  outgrown  even  under  favorable  condi- 
tions. Improper  attitudes 
that  favor  and  cause  deform- 
ity are  often  observed  among 
those  who  are  free  from 
weakness  and  disability  and 
from  the  influences  of  un- 
favorable surroundings ;  and 
such  attitudes  are,  of  course, 
more  likely  to  persist  in  those 
who  were  once  obliged  to 
assume  them  because  of 
weakness  and  deformity. 
Again  the  weakness  of  struc- 
ture or  function  may  be  an 
inherited  j)eculiarity,  or  it 
may  be  induced  by  disease  or 
by  improper  surroundings, 
influences  that  may  continue 
for  many  years  and  thus 
serve  to  check  the  natural 
tendency  toward  cure. 

The  observations  on  the  outgrowth  of  deformity  have  been 
confined,  as  a  rule,  to  the  period  of  childhood,  and  most  often 
they  have  been  made  with  reference  to  the  more  serious  grades 
of  distortion,  which  are  the  direct  result  of  rhachitis.  It  must 
be  borne  in  mind,  however,  that  the  true  significance  of  these 
deformities  in  the  adult  must  be  judged  from  the  aesthetic 
rather  than  from  the  medical  point  of  view,  and  although  the 
extreme  degrees  of  bow-leg  and  knock-knee  are  relatively  rare, 
^  New  York  Medical  Eecord,  July  30,  1887. 


A  type  of  deformity  in  which  the  prog- 
nosis  as  regards  outgrowth  is  bad. 


600 


OETHOPEDIC  SUBGEBY. 


yet  iu  the  minor  grade  both  deformities  are  very  common  in 
adult  males  and  in  all  probability  in  adult  females  also. 

In  1887  the  "^riter^  noted  among  2000  adult  males  observed 
on  the  streets  of  Boston  400  cases  of  bow-leg  and  32  cases  of 
knock-knee.  One  may  assume,  then,  that  the  legs  of  about  one 
adult  male  in  five  deviate  more  or  less  from  the  line  of  sym- 
metry— a  conclusion  that  has  been  confirmed  by  many  subse- 
quent observations.     It  may  be  admitted  that  a  certain  number 

Fig.  397. 


Extreme  deformities,   the  result  of  infantile   ihadiitib    The   left   leg  forms   prac- 
tically a  right  angle  with  the  thigh.      (See  Fig.  401.) 


of  the  distortions  under  consideration  are  acquired  during 
adolescence,  but  it  is  probable  that  the  greater  number  of  those 
that  may  be  noted  in  walkers  upon  the  streets  represent  the 
incomplete  outgrowth  of  a  deformity  of  childhood. 

The  statement  is  often  made  that  these  distortions  of  the  legs 
are  common  in  childhood  but  rare  in  adult  life.     Just  what  the 
^  N.  Y.  Med.  Record,  July  30,  1887. 


DEFORMITIES  OF  BONES  OF  LOWEB  EXTEEMITY.        601 

proportion  may  be  in  childhood  it  is  impossible  to  say,  but  it 
is  not  likely  to  be  greater  than  one  in  five.  One  must  conclude 
that  statistics,  on  which  such  statements  are  based,  have  been 
made  up  from  the  records  of  hospitals  where  it  is  unusual  for 
an  adult  to  apply  for  the  treatment  of  bow-leg,  to  which  he  has 
become  accustomed  since  childhood,  unless  the  deformity  is 
extreme  or  causes  discomfort. 

Granting  that  the  power  of  nature  is  quite  sufficient  to  modify 
or  to  cure  even  the  more  extreme  distortions  of  childhood,  still 
it  is  evident  that  this  natural  force  is  often  ineffective  in  com- 
pleting the  cure.  Therefore,  in  doubtful  cases  at  least,  one 
should  lend  assistance  in  that  class  of  patients  likely  to  appre- 
ciate the  advantage  of  symmetry  over  deformity,  even  though 
it  be  unattended  by  discomfort  or  disability. 

GENU  VALGUM. 

Synonyms. — Knock-knee,  in-knee. 

In  the  erect  posture  the  thighs,  whose  upper  extremities  are 
sej)arated  by  the  pelvis  and  by  the  projecting  femoral  necks, 


Fig.  398. 


Fiti.  399. 


Female. 
Tlie   normal    inclination    of   the   femora 


incline  slightly  inward  to  the  knees,  forming  an  angle  at  the 
knee,  opening  outward,  of  about  172  degrees.  This  angle  varies 
with  the  breadth  of  the  pelvis,  and  it  is,  therefore,  less  in  adult 
females  than  in  males  (Figs.  398  and  399).  The  internal  con- 
dyle of  the  femur  is  slightly  longer  than  the  external ;  thus  the 


602 


ORTHOPEDIC  SUBGEBT. 


inclination  of  the  femur  is  compensated  and  the  plane  of  the 
knee-joint  is  horizontal, 

Symptoms.^ — When  the  inward  projection  of  the  knees  is  in- 
creased to  a  noticeable  degree  the  tibise  are  no  longer  perpen- 
dicular; their  upper  extremities  incline  inward  so  that  in  the 
erect  posture  the  feet  are  separated  when  the  knees  are  in  con- 

FiG.  400. 


Adolescent  knock-knee.     Deformity   most  marked  in  tlie  tibiae.      (See  Fig.   403.) 


tact  (Fig.  400).  In  the  slighter  grades  of  knock-knee,  which 
are  due  in  great  degree  to  laxity  of  the  ligaments,  the  deformity 
is  apparent  only  when  the  weight  of  the  body  is  borne,  but  in 
more  marked  cases,  although  the  distortion  is  increased  by  the 
weight  of  the  body,  it  cannot  be  overcome  when  this  is  removed, 
because  it  depends  upon  actual  changes  in  the  shape  of  the 
bones  themselves. 

As  has  been  stated,  the  normal  inward  inclination  of  the  femur 


DEFOEMITIES  OF  BONES  OF  LOWER  EXTREMITY.        603 

is  compensated  by  the  greater  length  of  the  internal  condyle, 
and  in  the  deformity  of  knock-knee  the  plane  of  the  knee-joint 
is  still  preserved  by  an  apparent  elongation  of  the  inner  con- 
dyle. Formerly  it  was  supposed  that  there  was  an  actual  over- 
growth of  this  part  of  the  epiphysis  which  caused  the  deformity, 
but  the  observations  of  Mikulicz  and  Macewen  have  shown  that 
this  apparent  lengthening  is  in  reality  due  in  great  part  to  a 
deformity  of  the  lower  extremity  of  the  shaft  of  the  femur, 
which  is  so  bent  that  the  epiphyseal  line  has  an  increased  ob- 
liquity. And  the  hypothesis  that  bone  grows  more  rapidly  when 
relieved  from  weight  and  strain  has  been  disproved  by  Wolff, 
who  has  demonstrated  that  changes  in  the  bones  are  the  result 
of  accommodation  to  altered  function  and  attitude.  The  de- 
formity is  not  limited  to  the  femur;  in  most  instances  there  is 
a  similar,  although  usually  slighter,  irregularity  in  the  epiphy- 
seal line  of  the  upper  extremity  of  the  tibia,  the  shaft  being  so 
bent  that  when  it  is  placed  in  the  perpendicular  position  its 
internal  condylar  surface  is  higher  than  the  external.  In  some 
instances  the  primary  and  principal  deformity  is  of  the  shaft 
of  the  tibia,  the  distortion  being  most  marked  in  its  upper  third 
(Fig.  404). 

Changed  Relation  of  the  Femur  and  Tibia, — In  addition  to  the 
direct  deformities  of  the  bones  there  is  a  change  in  the  relation 
of  the  femur  to  the  tibia.  The  former  is  rotated  inward  and 
the  latter  is  rotated  outward.  In  some  instances  there  is  also  a 
certain  degree  of  overextension  at  the  knee.  This  is  more  often 
observed  in  the  adolescent  type,  in  which  there  is  laxity  of  the 
ligaments  (Fig.  400).  In  the  ordinary  form  of  rhachitic 
knock-knee  in  childhood  the  habitual  attitude  is  one  of  slight 
flexion  at  the  knees,  and  in  extreme  cases  there  may  be  actual 
limitation  of  the  range  of  extension  at  the  knee,  and  at  the  hip 
as  well. 

The  Accommodative  Attitude. — When  the  limb  is  fully  ex- 
tended the  deformity  is  most  marked,  because  the  shortened 
ligaments  and  tissues  on  the  outer  aspect  of  the  joint  become 
tense,  and  because  the  outward  rotation  of  the  tibia  is  increased. 
As  the  leg  is  flexed  the  deformity  lessens,  and  in  the  attitude  of 
complete  flexion  it  disappears  (Fig.  404).  This  is  explained 
by  the  fact  that  the  posterior  surface  of  the  condyles  is  not 
affected  by  the  deformity  of  the  shaft,  while  the  relaxation  of 
the  ligaments  and  the  outward  rotation  of  the  femora  allow  the 
tibiae  to  become  parallel  with  one  another.     This  accounts  for 


604 


OETEOPEDIC  SrEGE:RY. 


the  habitual  attitude  of  slight  flexion  T\'hich  is  so  often  assumed 
bv  patients  who  thus  unconsciously  accommodate  themselves 
to  the  deformity. 

/  Secondary  Deformities. — The  outward  inclination  of  the  leg- 
throws  more  weight  upon  the  inner  border  of  the  foot  and  tends 
to  depress  it  into  the  attitude  of  valgus.  Thus  knock-knee  in 
weak  children  is  often  accompanied  by  flat-foot,  but  in  the  more 

Fig.  401. 


Skiagram    of   Fig.    397,    showing   the   deformity   to   be   due   to   distortions   of   the 
diaphyses  of  the  bones,  while  the  epiphyses  are  practically  normal. 

extreme  grades  of  deformity  the  eft'orts  of  the  patient  to  com- 
pensate for  the  abnormal  separation  of  the  feet  may  result  in 
habitual  inversion  (Fig.  400)  ;  in  fact,  confirmed  and  extreme 
knock-knee  in  older  subjects  is  usually  accompanied  by  a  slight 
degi-ee  of  varus  that  ]3ecomes  very  evident  after  the  correction 
of  the  deformity  by  operation.  Even  in  the  mildest  type  of 
knock-knee  this  compensatory  and  conservative  effort  of  nature 
is  shown  by  the  so-called  pigeon-toed  walk,  which  is  often  the 
first  symptom  that  attracts  attention. 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.        605 


Fig.  402. 


Gait.- — The  gait  of  the  patient  with  well-marked  genu  valgTim 
is  peculiarly  awkward  and  shambling.  The  knees  "  interfere  " 
and  must  be  assisted,  as  it  were,  in  the  effort  to  pass  one  another 
in  walking.  In  the  slighter  cases  the  thigh  is  abducted  and 
rotated  outward  at  the  moment  of  passing  its  fellow,  the  move- 
ment being  then  reversed  as  it, 
in  its  turn,  supports  the  weight ; 
but  in  the  more  severe  type  this 
voluntary  effort  of  the  muscles 
of  the  leg  is  not  sufficient,  and, 
in  addition,  the  body  is  swayed 
from  side  to  side  and  the  legs 
are  alternately  swung  outward 
and  lifted  around  one  another. 

The  deformity  and  the  effects 
of  the  deformity  on  the  gait 
and  attitude  are  the  most  im- 
portant symptoms,  as  of  other 
distortions  of  similar  origin. 
The  patient  is,  as  a  rule,  easily 
fatigued,  and  pain  during  the 
progressive  stage,  referred  to 
the  inner  side  of  the  knee, 
where  the  ligaments  are  sub- 
jected to  continuous  strain  is  a 
common  symptom,  particularly 
in  the  adolescent  type  of  genu 
valgum. 

Unilateral    Knock -knee. — This 
description    refers    particularly 
to  the  cases   in  which  the   de- 
formity is  bilateral.     I^ot  infre- 
quently it  is  unilateral,  the  limb 
being  so  shortened  by  the  dis- 
tortion that  a  well-marked  limp  replaces  the  swaying  gait.     The 
pelvis  is  tilted  toward  the  short  limb,  while  the  body  is  inclined 
in  the  opposite  direction,  thus  in  cases  of  long  standing  a  per- 
manent curvature  of  the  lumbar  spine  may  be  present. 

Knock-knee  Combined  with  Bow-leg  and  with  General  Rhachitic 
Distortions. — Occasionally  the  unilateral  knock-knee  may  be  ac- 
companied by  an  outward  bowing  of  its  fellow;  and  in  the 
marked   distortions  of  the  lower   extremity,   induced  by   rha- 


Deformity    of  the   femur    in    genu   val- 
gum.     (Mikulicz.) 


606  OBTEOPEDIC  SUBGEBY. 

chitis,  the  bones  may  be  twisted  and  bent  in  various  directions, 
although  the  outward  expression  of  the  deformity  may  be  genu 
valgum.  For  example,  the  femora  may  be  bent  forward  and 
outward  above  and  inward  and  backward  below,  while  the  tibia? 
may  be  bent  inward  above  and  outward  and  forward  below. 

Fig.  403. 


Knock-knee  and  bow-leg. 

In  other  instances,  especially  in  the  slighter  rhachitic  de- 
formities, an  outward  bowing  of  the  leg  mnj  accompany  a  slight 
degree  of  knock-knee,  so  that  it  may  be  difficult  to  classify  the 
deformity. 

In  the  more  extreme  deformities  of  the  rhachitic  type  the 
shape  as  well  as  the  contour  of  the  bones  is  markedly  modified, 
for  example,  the  internal  border  of  the  tibia  may  become  very 


DEFORMITIES  OF  BONES  OF  LOWEB  EXTEEMITY. 


607 


prominent  at  its  upper  extremity,  and  may  project  beneath  the 
skin  like  an  exostosis  (Fig.  403).  A  change  in  the  contour  of 
the  fibula  accompanies  and  corresponds  to  that  of  the  tibia, 
although  it  is,  as  a  rule,  much  less  pronounced.  As  has  been 
stated,  the   internal   structure  or  architecture   of  the   affected 

Fig.  404. 


Adolescent   knock-knee,   showing   the   disappearance   of    the    deformity   when   legs 
are  flexed.      (See  Fig.  400.) 

bones  is  changed  to  accommodate  the  new  static  conditions,  and 
according  to  Wolff  the  internal  change  precedes  the  external 
deformity. 

Measurements, — There  are  various  methods  of  measuring  the 
deformity.  One  of  the  simplest  and  most  practical  is  to  trace 
the  outlines  on  paper,  while  the  child  is  seated  with  the  limbs 
fully  extended,  the  knees  being  sufficiently  separated  to  allow 
the  pencil  to  pass  between  them.  The  increase  of  the  deformity, 
depending  upon  the  laxity  of  the  ligaments  and  upon  the  out- 
ward rotation  of  the  tibise,  may  be  estimated  by  measuring  the 
distance  between  the  two  internal  malleoli  when  the  patient 
stands,  the  knees  being  slightly  separated  as  before,  and  com- 
paring this  measurement  with  that  between  the  similar  points 
in  the  tracing. 

Pathology.- — In  knock-knee  due  directly  to  rhachitis  the 
changes  in  the  bones  and  in  the  epiphyseal  cartilages  are  char- 
acteristic of  that  affection,   but  in  the  milder  grades  of  de- 


608  ORTHOPEDIC  SURGEBY. 

formity,  aside  from  the  change  in  the  contour  of  the  bones,  the 
transformation  of  the  internal  structure,  and  in  some  instances 
slight  thickening  or  irregularity  of  the  epiphyseal  cartilages, 
there  is  little  noteworthy  change  from  the  normal  (Fig.  402). 
The  tissues  on  the  internal  aspect  of  the  joint  are  relaxed;  those 
on  the  outer  side,  the  lateral  ligaments,  the  capsule,  and  the 
biceps  muscle,  are  contracted  and  resist  the  reduction  of  the 
deformity.  In  the  interior  of  the  joint  slight  changes  in  the 
articulating  surfaces  of  the  bones  and  evidences  of  chronic  irri- 
tation to  the  synovial  membrane  have  been  described. 

In  the  early  stage  of  progressive  knock-knee,  particularly  in 
the  type  not  caused  directly  by  rhachitis,  laxity  of  ligaments 
and  the  habitual  assumption  of  the  attitude  of  rest  will  account 
for  the  deformity,  which  the  patient  may  be  able  to  overcome, 
in  great  degree  at  least,  by  voluntary  effort.  This  voluntary 
control  of  the  deformity  is  very  suggestive',  as  indicating  certain 
factors  in  its  etiology,  and  the  principles  that  should  be  fol- 
lowed in  its  treatment. 

Treatment. — The  treatment  of  the  deformity  under  considera- 
tion may  be  classified  as  expectant,  mechanical,  and  operative. 
Expectant  Treatment. — This  should  not  be  expectant  in  the 
sense  that  nothing  is  done  to  correct  the  deformity,  but  expec- 
tant in  that  more  positive  treatment  by  braces  or  by  operation 
is  delayed  or  avoided  if  it  proves  to  be  unnecessary. 

During  this  period  the  predisposing  cause  of  the  deformity, 
if  it  is  constitutional,  should  receive  proper  dietetic  or  i^iedi- 
cinal  treatment,  as  already  described  in  the  chapter  on  Eha- 
chitis.  And,  if  possible,  the  direct  exciting  causes  of  the  de- 
formity must  be  removed — that  is  to  say,  the  improper  attitudes, 
or,  in  the  adolescent,  the  predisposing  occupations  should  be 
discontinued.  General  massage  of  the  limbs  may  be  employed 
with  advantage;  in  older  children  special  exercises  may  be 
practised,  and  in  all  cases,  whether  braces  are  used  or  not,  direct 
manipulation  of  the  distorted  limbs  is  of  the  first  importance. 
Manipulation. — The  limbs  should  be  vigorously  massaged  at 
morning  and  night,  and  forcibly  straightened.  The  latter  pro- 
cedure is  conducted  as  follows :  The  patient  is  seated  in  a  chair, 
the  limb  being  fully  extended  so  that  the  deformity  is  made  as 
extreme  as  possible.  One  hand  then  clasps  the  knee,  the  palm 
lying  against  its  inner  aspect ;  with  the  other  the  calf  is  grasped 
firmly  and  the  leg  is  then  gently  straightened  over  the  fulcrum 
formed  by  the  palm  of  the  hand,  and  is  held  in  the  corrected 


DEFOBMITIES  OF  BONES  OF  LOWER  EXTREMITY.        609 

position  for  a  moment.  This  manipulation  should  be  continued 
with  gradually  increasing  force,  although  not  to  the  extent  of 
causing  actual  pain,  for  ten  minutes  at  least  twice  in  the  day 
and  oftener  if  possible. 

Posture  and  Exercise. — It  has  been  stated  that  genu  valgum  is 
often  accompanied,  especially  in  the  rhachitic  cases,  by  flat- 


FiG.  405. 


Tig.  406. 


The  Thomas  knock-knee  brace. 


Thomas  knock-knee  brace  with  pelvic  band. 
The  pelvic  band  may  be  divided  also,  the  two 
parts  being  joined  by  straps   (Fig.  407). 


foot,  while  in  another  type  the  inversion  of  the  feet,  or  in  the 
more  severe  cases  the  actual  fixed  attitude  of  varus,  indicates 
the  effort  of  nature  to  withstand  and  to  compensate  for  the  de- 
formity at  the  knee.  This  serves  as  an  indication  to  thicken  the 
soles  of  the  shoes  on  the  inner  border  or  to  apply  braces  as  in  the 
treatment  of  flat-foot,  in  order  to  throw  the  strain  upon  the 
39 


610  OBTHOPEDIC  SUBGEBY. 

outer  border  of  the  foot.  The  patient  should  be  instructed  to 
walk  with  the  feet  parallel  with  one  another,  and  for  older 
children  the  tip-toe  exercises,  in  which  the  body  is  raised  upon 
the  toes  as  many  times  as  the  strength  permits,  or  games  or 
exercises  in  which  the  legs  are  extended  should  be  encouraged. 
Such  exercises  are  often  efficacious  in  the  early  stage  of  adoles- 
cent knock-knee,  for,  as  has  been  mentioned,  genu  valgum  is  an 
exaggeration  of  the  attitude  of  rest;  therefore,  its  progress 
should  be  checked  by  the  assumption  of  the  attitudes  proper  to 
activity.  Bicycle  riding,  and  particularly  horseback  riding 
may  be  recommended  also  in  this  class  of  cases.  A  record  of  the 
deformity  should  be  kept  during  this  tentative  treatment,  and 
if  it  improves  somewhat  one  is  justified  in  delaying  the  more 
radical  measures.  This  question  may  be  decided,  as  a  rule,  in 
three  months  if  instructions  are  faithfully  followed. 

Treatment  by  Braces. — ^The  most  efficient  brace  for  the  treat- 
ment of  genu  valgum  is  the  simple  straight  steel  bar  or  splint 
extending  from  the  trochanter  to  the  heel  of  the  shoe,  without 
joint  at  the  knee.  The  greater  efficacy  of  the  rigid  bar  as  com- 
pared with  the  jointed"brace  is  explained  by  the  fact  that  the 
rectifying  force  acts  constantly  when  the  joint  is  fixed,  and  be- 
cause, in  many  instances,  the  patient  habitually  fiexes  the  knees 
so  that  direct  pressure  cannot  be  made  upon  the  deformity  by 
a  brace  that  permits  this  attitude. 

The  Thomas  Brace. — The  simplest  and  cheapest  brace  is 
that  of  Thomas,  which  consists  of  a  light  steel  bar  provided  with 
a  pad  at  its  upper  end  for  pressure  against  the  trochanter,  while 
the  lower,  rounded  extremity  is  turned  inward  at  a  right  angle, 
to  pass  through  the  heel  of  the  shoe.  The  knee  is  fixed  by  a 
posterior  bar  attached  to  a  thigh  and  calf  band,  as  illustrated  in 
the  figure.  When  the  brace  is  applied  the  knee  is  drawn  back- 
ward and  outward  and  is  attached  firmly  to  the  brace  by  a 
roller  bandage  (Fig.  405). 

In  the  more  extreme  cases  in  which  the  knees  and  thighs  are 
habitually  flexed,  the  addition  of  a  pelvic  band  attached  to  the 
uprights  by  a  free  joint  at  the  hips  adds  to  the  comfort  and  effi- 
ciency of  the  apparatus,  as  the  attitude  of  outward  or  inward 
rotation  can  be  regulated  by  twisting  the  uprights  slightly.  Or 
preferably  the  pelvic  band  may  be  divided  and  attached  by 
means  of  straps  on  the  front  and  back.  The  uprights  may  be 
bent  somewhat  inward  at  first,  and  as  the  legs  become  straighter 
they  are  straightened  and  finally  bent  slightly  outward  to  allow 


DEFORMITIES  OF  BONES  OF  LOWEB  EXTBEMITY. 


611 


for  the  over-correction  of  the  deformity  (Fig.  407).  Twice  a 
day  the  braces  should  be  removed  for  massage,  manipulation, 
and  for  voluntary  exercises  of  the  limbs.  In  most  cases  the 
braces  are  not  employed  at  night,  although  the  rectification  of 
the  deformity  may  be  hastened  by  their  constant  use. 

Fig.  407. 


Modified    Thomas    kuock-kuee    braces    applied. 


If  the  deformity  is  unilateral  so  that  a  brace  is  required  for 
one  limb  only,  the  other  shoe  should  be  raised  by  a  cork  sole 
about  three-quarters  of  an  inch  in  thickness,  to  make  walking 
easier.  Children  soon  become  accustomed  to  the  braces  and 
walk  easily  in  spite  of  the  absence  of  joints  at  the  knees. 

Another  simple  and  efficient  brace  is  that  used  at  the  Chil- 
dren's Hospital  at  Boston  (Fig.  408).     The  upper  part  of  the 


612 


OBTHOPEDIC  SUBGEBY. 


Fig.  408. 


TO 


D^= 


CZ7 


brace  is  turned  backward  and  upward  to  lie  against  the  buttock, 
and  tbe  feet  can  be  rotated  in  or  out  by  lengthening  or  shorten- 
ing straps  passing  before  and  behind  the  body.  Braces  jointed 
at  the  knee  are  sometimes  employed,  but  they  are,  as  a  rule, 
ineffective,  except  in  the  slighter  cases  in  which  the  deformity 
depends  upon  laxity  of  ligaments  rather  than  distortion  of  bone. 

Duration  OF  Treatment  BY 
Braces. — The  duration  of  the 
brace  treatment  depends,  of 
course,  upon  the  degree  of  de- 
formity, the  age  of  the  child, 
and  upon  the  efficiency  of  the 
apparatus.  From  six  months  to 
one  year  of  treatment  by  this 
means  is  usually  required.  The 
cure  is  assured  by  -the  gradual 
adaptation  of  the  parts  to  the 
new  static  conditions.  The  con- 
tracted tissues  of  the  outer  as- 
pect of  the  joint  become  length- 
ened; the  lax  ligaments  on  the 
inner  side  contract ;  the  internal 
structure  of  the  condyles  and  of 
the  adjoining  diaphysis  is  grad- 
ually transformed  and  at  the 
external  contour  of  the  bone 
becomes  correspondingly 
straighter.  When  the  braces  are 
discarded  attention  should  be 
paid  to  the  attitudes,  and  the 
exercises  that  have  been  men- 
tioned should  be  continued  in  order  that  relapse  may  be  pre- 
vented. 

The  Plaster  Bandage. — ^When  the  bones  are  yielding,  as 
in  young  children,  the  deformity  may  be  corrected  by  the  re- 
peated applications  of  plaster  bandages,  the  limbs  being  straight- 
ened as  far  as  possible  without  causing  discomfort  at  each  sit- 
ting, or  it  may  be  corrected  at  once  by  manual  force  under 
anaesthesia,  which  is  the  better  method. 

Operative  Treatment.. — Immediate  correction  of  the  deformity, 
when  it  is  at  all  marked,  is,  as  a  rule,  indicated  after  the  age  of 
four  or  five  years,  and  is  a  satisfactory  treatment  at  any  age 


Long    braces    for    genu    valgum. 
(Bradford    and    Lovett.) 


DEFORMITIES  OF  BONES  OF  LOWEB  EXTBEMITT.        613 

except  during  the  period  of  active  rhachitis.  It  is  perhaps 
needless  to  remark  that  the  necessity  for  operation  implies 
neglect  of  proper  preventive  treatment  or  the  failure  of  the 
manipulative  and  mechanical  methods,  because  of  their  im- 
proper application.  While  it  is  possible  to  correct  deformity 
of  the  bones  by  mechanical  treatment  in  cases  far  beyond  this 
limit  of  age,  the  time  required  and  the  discomforts  of  the  treat- 
ment exclude  it  in  all  but  very  exceptional  cases. 

Osteotomy. — In  1909  sixty-four  cases  of  knock-knee  were 
operated  on  at  the  Hospital  for  Ruptured  and  Crippled ;  29  per 

Fig.  409. 


The  Grattan  osteoclast. 

cent,  of  the  new  cases  recorded  in  the  out-patient  department. 
The  usual  operation  was  osteotomy  (64  cases)  by  means  of  the 
small  Vance  osteotome,  the  so-called  "  subcutaneous  osteotomy." 
In  a  certain  proportion  of  the  cases  the  bones  of  the  thigh  and 
leg  are  equally  involved  in  the  deformity.  In  others  the  tibia 
is  the  more  distorted,  but  in  most  instances  the  correction  of  the 
deformity  of  the  femur  will  practically  restore  the  normal  con- 
tour (Fig.  402). 

The  limb  having  been  prepared  in  the  usual  manner  is  semi- 
flexed, and  the  inner  surface  of  the  knee  is  placed  on  a  firm 
sand-bag.  With  the  fingers  the  femur  is  firmly  grasped  just 
above  the  condyles,  so  that  its  size  and  position  may  be  accu- 
rately determined,  and  the  sharp  osteotome  about  the  size  of  a 
lead-pencil  is  forced  with  its  cutting  edge  parallel  to  the  axis  of 
the  thigh  down  to  the  bone,  at  a  point  about  one  and  a  half 
inches  above  the  external  tuberosity.     While  it  is  held  firmly  in 


614  OBTHOPEDIC  SUBGEBY. 

position  against  the  bone  it  is  turned  to  the  transverse  direction 
and  is  then  driven  through  the  cortex.  When  it  enters  the 
medullary  canal,  as  is  made  evident  bj  the  lessened  resistance, 
it  is  partly  withdrawn  and  moved  slightly  to  one  side  and  the 
other,  and  driven  through  the  cortical  substance  until  by  gentle 
force  the  bone  may  be  fractured.  The  osteotome  is  then  with- 
drawn; the  minute  wound  is  covered  with  a  pad  of  dry  gauze, 
or,  if  the  oozing  is  profuse,  it  may  be  closed  with  a  catgut 
suture.  The  deformity  is  then  overcorrected  sufficiently  to 
simulate  well-marked  genu  varum,  and  a  plaster  spica  bandage 
is  applied.  If  the  deformity  is  bilateral  both  limbs  are  operated 
upon  at  the  same  sitting. 

The  i^laster  bandage  is  continued  for  from  four  to  six  weeks, 
and  it  is  then  usually  supplemented  by  a  brace,  which  may  be 
worn  with  advantage  for  several  months,  because  of  the  laxity 
of  the  ligaments  of  the  knee-joint,  which  usually  accompanies 
extreme  deformity  of  rhachitic  origin.  In  less  marked  cases 
and  in  older  subjects  the  support  is  unnecessary.  Massage  and 
exercises  during  the  stage  of  recovery  should  be  employed  if 
possible. 

Incomplete  osteotomy  and  fracture  in  the  manner  described 
have  been  employed  at  the  Hospital  for  Ruptured  and  Crippled 
in  a  very  large  number  of  cases  without  an  unfavorable  result. 
The  discp^fort  is  insignificant,. and  confinement  to  the  bed  after 
the  third  day  is  unnecessary. 

CuNEiFOKM  Osteotomy. — In  the  more  extreme  cases  of  gen- 
eral rhachitic  deformity  of  the  lower  extremity  in  which  the 
tibia  is  implicated,  it  is  sometimes  advisable,  in  addition  to  the 
osteotomy  of  the  femur,  to  remove  a  cuneiform  section  of  bone 
from  the  inner  side  of  the  tibia  just  below  the  epiphysis,  in  order 
to  straighten  the  leg  completely.  In  such  cases  it  is  better  to 
perform  the  second  operation  at  a  later  time,  in  order  that  the 
effect  of  the  femoral  osteotomy  may  be  observed.  In  exceptional 
cases  the  deformity  may  be  practically  confined  to  the  tibia ;  in 
such  instances  it  should  be  corrected  by  a  primary  cuneiform  or 
linear  osteotomy. 

Osteoclasis. — Osteoclasis,  by  means  of  the  Grattan  osteo- 
clast, is  an  effective  operation.  With  this  instrument  the  bone 
may  be  broken  above  the  condyles  at  the  desired  point.  The 
lower  resistant  bar  is  applied  over  the  external  cond^de,  the 
upper  about  four  inches  higher.  The  limb  is  then  firmly  fixed 
by  the  hands  of  an  assistant,  and  the  breaking  bar  is  screwed 


3 


DEFOBMITIES  OF  BONES  OF  LOWEB  EXTREMITY.        615 

rapidly  home,  breaking  or  bending  the  bone  at  the  point  of 
election.  The  deformity  is  then  overcorreeted  in  the  manner 
described.  ilSTot  infrequently  in  rhachitic  cases  the  principal  or 
primary  distortion  is  of  the  tibia.  In  such  cases  the  correction 
is  made  at  this  point.  If  it  is  necessary  to  operate  upou  both 
the  femur  and  the  tibia  the  osteoclast,  which  bends  and  breaks, 
is  to  be  preferred  to  osteotomy. 

The  adolescent  type  of  genu  valgum  is  not  often  extreme. 
As  a  rule,  the  deformity  of  the  bone  is  of  comparatively  short 
duration,  and  it  is  accomjDanied  by  considerable  laxity  of  liga- 
ments. In  the  more  chronic  cases  the  osteotomy  above  the 
condyles  may  be  performed  in  the  manner  described. 

Wolif's  treatment  of  gradual  correction  by  plaster-of-Paris 
bandages  ("Etappen  Verband")  and  Loreuz's  method  of  epi- 
physeal separation  described  in  former  editions  have  been 
omitted  as  offering  no  advantage  over  osteoto^my  or  osteoclasis. 

It  may  be  noted  that  paralysis  clue  to  injury  of  the  peroneal 
nerve  may  follow  the  correction  of  knock-knee.  In  a  total  of 
1863  operations  by  osteoclasis  reported  by  Codivilla^  there  were 
34  instances  of  the  paralysis,  2  of  which  were  permanent. 

GENU  VARUM. 

Synonym. — Bow-leg. 

The  term  bow-leg  includes,  in  its  popular  sense,  ^all  the  dis^ 
tortious  that  caiTse  a  separation  of  the  knees  when  the  ankles  are 
in  contact  with  one  another.  But,  strictly  speaking,  genu  varum 
is  the  reverse  of  genu  valgum — that  is,  the  principal  distortion 
is  at  or  near  the  knee-joint — while  bow-leg,  as  the  name  implies, 
is  a  simple  bowing  of  the  tibia  and  fibula,  as  a  rule  near  the 
ankle  joint  (Fig.  417) .  In  true  genu  varum  a  line  dropped  from 
the  head  of  the  femur  falls  inside  the  knee  (Fig.  396)  ;  the 
inner  condyle  of  the  femur  and  the  inner  tuberosity  of  the  tibia 
bear  the  greater  part  of  the  weight;  the  outer  condyle  is  on  the 
same  level  or  somewhat  lower  than  the  internal,  and  the  outer 
tuberosity  of  the  tibia  may  be  somewhat  higher  than  the  inter- 
nal. The  femur  is  abducted  and  rotated  outward;  the  tibia  is 
rotated  inward.  These  changes,  it  will  be  noted,  are  the  reverse 
of  those  found  in  genu  valgum.  As  has  been  stated,  the  de- 
formity of  genu  valgum  disappears  on  flexion,  and  in  genu 
varum,  if  the  limbs  are  flexed  and  the  knees  are  placed  in  con- 
tact with  one  another,  the  malleoli  may  be  actually  separated, 

'Zeits.  f.  Orth.  Chir. 


616 


ORTHOPEDIC  SURGERY. 


simulating  the  deformity  of  knock-knee  (Fig.  411).  This  is 
explained  by  the  inward  rotation  of  the  femora,  necessitated  by 
placing  the  knees  in  contact  with  one  another. 

In  genu  varum  the  distortion  of  the  bones  is  not  as  strictly 
confined  to  the  neighborhood  of  the  knee-joint  as  in  genu  val- 
gum, and  in  simple  bow-leg  there  is  almost  always  a  certain 


Fig.  410. 


Fig.  411. 


The  genu  varum  type  of  bow-leg, 
showing  the  outward  rotation  of  the 
femora. 


The  same  patient,  showing  the  sepa- 
ration of  the  malleoli  when  the  knees 
are   in   contact. 


degree  of  distortion  at  the  knee,  dependent,  in  part,  upon  laxity 
of  the  ligaments.  It  is  proper,  therefore,  to  use  the  two  terms 
synonymously,  although  one  must  recogiiize  a  decided  difference 
between  the  genu  varum  type,  in  which  the  deformity  is  greatest 


DEFOBMITIES  OF  BONES  OF  LOWEE  EXTBEMITY.        617 

at  the  knee,  and  which  is  accompanied,  as  a  rule,  by  marked 
laxity  of  the  ligaments  (Fig.  412)  and  the  bow-leg  type,  in 
which  the  deformity  may  be  limited  to  the  lower  third  of  the 
leg  (Fig:  417). 

Symptoms. — As  was  said  of  genu  valgum,  the  deformity  is 
the  principal  symptom.  The  gait  is  somewhat  rolling,  because 
each  foot  must  describe  a  part  of  the  arc  of  a  circle  before  reach- 

FiG.  412. 


Genu  varum  of  rhachitic  origin  in  an  adult. 

ing  the  ground ;  and  because  of  the  inward  rotation  of  the  tibiae, 
or  because  of  the  inward  spiral  twist  of  the  bone  that  is  some- 
times present,  patients  often  toe-in  in  walking. 

Except  in  extreme  cases  the  weakness  and  awkwardness  char- 
acteristic of  genu  valgum  are  absent.  This  may  be  explained  by 
the  fact  that  the  relation  of  the  bones  is  such  that  the  general 
attitude  is  one  of  activity,  the  weight  falling  on  the  outer  side  of 
the  feet;  thus  the  weak  foot  is  uncommon  as  an  accompaniment 
of  bow-leg,  except  in  the  early  or  rhachitic  type  or  as  a  com- 
pensatory deformity  in  older  subjects. 


618 


OBTEOPEDIC  SUEGEEY. 


Fig.  413. 


Measurements.. — The  full  effect  of  the  deformitv  appears  only 
when  the  weight  of  the  body  is  borne,  but  for  practical  purposes 
the  tracing  of  the  extended  legs  is  the  best  method  of  recording 
the  fixed  deformitv.  In  true  genu  varum  the  deformity  is 
greatest  at  the  knee,  and  in  the  distortion  the  apposed  surfaces 
of  the  femur  and  of  the  tibia  participate. 

In  simple  bow-leg  the  deformity 
may  be  confined  to  the  tibia,  which  in 
addition  to  the  outward  bowing,  may 
be  twisted  inward  somewhat  upon  its 
long  axis. 

Genu  varum  may  be  unilateral  or 
it  may  be  combined  with  genu  val- 
gum of  its  fellow  (Fig.  4:03),  and 
occasionally  slight  knock-knee  and 
slight  bow-leg  may  be  present  in  the 
:^ame  limb. 

Treatment. — Expectant  Treatment. 
— The  slighter  cases  of  bow-leg  in 
early  childhood  may  be  treated  by 
manipulation.  The  leg,  grasped 
firmly  at  the  ankle  and  at  the  knee, 
is  straightened  with  a  certain  amount 
of  force  over  and  over  again.  Grad- 
ual correction  by  this  means  may  be 
hastened  by  making  the  sole  of  the 
shoe  slightly  thicker  on  the  outer 
border.  This  aids  also  in  correcting 
the  secondary  pigeon-toe,  but  if  the 
foot  is  weak,  as  it  usually  is  in  rha- 
chitic  cases,  this  method  should  not  be  employed,  as  it  might 
induce  flat-foot. 

Treatment  by  Braces. — If  the  deformity  is  more  extreme,  or  if 
improvement  does  not  follow  expectant  treatment,  apparatus 
should  be  employed.  If  the  distortion  is  confined  to  the  lower 
third  of  the  tibia  a  Knight  brace  may  be  used.  It  consists  of 
two  uprights  attached  to  a  foot-plate;  the  inner  bar  is  provided 
with  a  pad  at  its  upper  end  for  pressure  on  the  internal  condyle 
of  the  femur.  The  outer  bar  reaches  to  the  head  of  the  fibula, 
and  the  two  are  joined  by  a  calf  band  (Fig.  414).  When  ap- 
plied the  leg  is  drawn  toward  the  inner  upright  by  means  of  a 
lacing,  which  passes  about  it  within  the  outer  bar.     "When  the 


Long   braces   for   genu   varum. 
(Bradford  and  Lovett.) 


DEFOBMITIES  OF  BONES  OF  LOWER  EXTBEMITT. 


619 


lacing  is  made  fast,  the  outer  bar  is  adjusted  to  the  contour  of 
the  leg,  and  thus  it  aids  somewhat  in  supporting  it  in  an  im- 
proved position.  The  foot-j^late  may  be  dispensed  with,  and 
the  brace  mav  be  attached  to  the  shoe,  and  even  the  outer  bar 
may  be  removed,  leaving  only  the  uj)right,  which  is  held  in 
position  by  the  lacing.  The  apparatus,  then,  has  the  appearance 
of  a  gaiter,  and  has  the  advantage  of  being  inconspicuous, 
although  somewhat  less  effective  than  the  Knight  brace.  If 
the  support  is  supplemented  by  vigorous  manipulation  the  de- 
formity may  be   corrected,   in  young  children,    in   about   six 

months. 

Fig.  414. 


The   long    (Napier)    and   short    (Knightj    bow-leg  brace. 


If  the  outward  bowing  of  the  knee  is  marked  another  form  of 
apparatus  will  be  necessary,  and  its  effectiveness  will  be  much 
increased  if  there  is  no  joint  at  the  knee.  The  inner  bar  reaches 
to  the  upper  third  of  the  thigh.  An  inner  straight  bar  extends 
to  the  upper  third  of  the  thigh,  and  is  attached  to  the  outer  bar 
by  a  thigh  band.  This  inner  upright  is  provided  with  a  lacing 
of  leather  or  canvas,  similar  to  that  of  the  short  brace,  which 
surrounds  the  knee  and  upper  part  of  the  leg,  and  thus  draws  it 
toward  an  improved  position  (Fig.  -414). 


620  OETROFEDIC  SURGEEY. 

Another  form  of  brace  is  used  at  tlie  Boston  Children's  Hos- 
pital, in  which  the  nj)per  part  of  the  upright  is  curved  upward 
and  outward  just  below  the  groin,  to  a  point  on  a  level  with  and 
behind  the  trochanter,  and  is  attached  to  its  fellow  by  means 
of  a  strap  passing  across  the  buttocks  so  that  the  feet  may  be 
somewhat  rotated  outward  if  necessary  (Fig.  413). 

Operative  Treatment. — In  children  more  than  four  years  of 
age,  and  in  cases  of  the  more  extreme  type  at  an  earlier  age,  or 
when  the  opportunity  for  mechanical  treatment  is  lacking,  or 
if  rapid  cure  is  desired,  operative  correction  of  the  deformity  is 
indicated.  Either  osteoclasis  or  osteotomy  may  be  employed, 
and  in  some  instances  manual  force  is  sufficient  for  the  correc- 
tion of  the  deformity.  There  is  but  little  choice  between  the 
methods.  Osteoclasis  is  somewhat  safer  possibly,  and  is  to  be 
preferred  for  the  younger  patients. 

At  the  Hospital  for  Ruptured  and  Crippled  in  1909,  '15 
patients,  or  about  10  per  cent,  of  the  new  cases  of  bow-leg 
recorded  in  the  out-door  department,  440  were  admitted  for  oper- 
ation. Osteotomy  is  usually  performed.  The  small  osteotome  is 
inserted  on  the  inner  aspect  of  the  tibia  at  the  point  of  greatest 
deformity,  and  when  the  bone  has  been  sufficiently  weakened 
the  fracture  is  completed  by  manual  force.  The  fibula  may  be 
broken  at  the  same  time,  or,  as  is  usually  the  case,  it  may  be 
simply  bent  outward.  The  deformity  is  overcorrected,  and  a 
well-fitting  plaster  bandage,  including  the  foot  and  extending 
to  the  trochanter,  is  applied. 

The  patient  usually  remains  in  bed  for  a  few  days ;  he  is  then 
dressed,  and  if  he  so  desires  is  allowed  to  stand.  Amost  no  pain 
or  discomfort  follows  the  operation,  and  in  fact,  in  properly 
selected  cases,  it  is  not  only  free  from  danger,  but  it  has  a  very 
decided  advantage  over  the  ordinary  mechanical  treatment.  If 
the  child  is  in  good  condition,  and  if  the  deformity  is  overcor- 
rected at  the  time  of  operation,  apparatus  will  not  be  required 
in  the  after-treatment ;  but  in  many  instances  some  form  of 
support  is  indicated,  usually  because  slight  deformity,  due  to 
laxity  of  ligaments  or  to  deformity  of  the  femur,  apj)ears  when 
the  weight  of  the  body  falls  upon  the  legs.  - 

It  has  been  stated  that  the  deformity  of  bow-legs  depends  in 
part  upon  a  distortion  of  the  femur  as  well  as  of  the  tibia.  As 
a  rule,  the  correction  of  the  gTcater  deformity  of  the  tibia  will 
be  sufficient,  but  in  more  extreme  cases  a  secondary  osteotomy 
above  the  condyles  will  be  necessary.     This  may  be  performed 


DEFORMITIES  OF  BONES  OF  LOWEB  EXTBEMITY.        621 

sinmltaneously  with  that  on  the  tibia,  but  it  is  better  to  defer 
it  until  the  effect  of  the  primary  operation  has  been  observed. 

ANTERIOR  BOW-LEG. 

Synonym. — Anterior  curvature  of  the  tibia. 
Both  bow-leg  and  knock-knee  are  aften  seen  in  children  who 
present  no  signs  of  general  rhachitis,  but  anterior  bowing  of  the 

Fig.  415. 


Anterior   bow-les 


legs  is  almost  always  combined  with  general  rhachitic  distor- 
tions of  the  lower  extremity,  most  often  with  knock-knee.  These 
in  turn  are  caused  by  marked  distortion  of  the  femora,  which 
may  be  bent  forward  and  outward  above,  and  inward  at  their 
lower  extremities,  "  corkscrew  deformity."  In  anterior  bow- 
leg the  tibiae  are  usually  flattened  from  side  to  side,  curved  in- 
ward or  outward  arid  bent  forward,  the  projecting  crests  pre- 
senting sharply  beneath  the  skin. 

Sjmaptoms. — The  effect  of  the  anterior  bowing  is  to  throw  the 
weight  forward  upon  the  foot;  thus  the  heels  appear  ab- 
normally long  and  prominent,  and  the  patient  seems  to  sink  for- 
ward at  each  step  (Fig.  415).  The  knees  are  usually  somewhat 
flexed,  partly  as  the  effect  of  knock-knee,  with  which  the  de- 
formity is  usually  combined,  and  the  feet  are,  as  a  rule,  flat. 
As  has  been  stated,  anterior  bowing  is  almost  never  seen  as  an 
independent  deformity  unless  it  is  a  relic  of  the  more  general 
distortion  which  has  been  "  outgrown." 


Fig.  416. 


Long  anterior  curvature  of  the  tibia  and  flat-foot. 
Fig.  417. 


Rhachitic  anterior  bow-leg. 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.        623 

Treatment. — Anterior  curvature  of  the  tibia  must,  as  a  rule^ 
be  treated  by  operation,  preferably  osteotomy.  After  complete 
fracture  of  the  tibia  and  fibula  the  deformity  may  be  overcome 
by  forcing  the  bones  directly  backward.  In  many  instances 
tenotomy  of  the  tendo  Achillis  may  be  required.  Cuneiform 
osteotomy  of  the  tibia  permits  more  perfect  correction,  but  the 
final  result  is  equally  good  after  simple  osteotomy  or  osteoclasis, 
and  if  one  succeeds  in  separating  the  posterior  part'  of  the  tibia 
so  that  it  may  conform  to  the  straightened  anterior  border  an 
actual  elongation  may  be  obtained. 

GENERAL  RHACHITIC  DISTORTIONS. 

General  rhachitic  distortions  of  the  lower  limbs  have  been 
mentioned  in  connection  with  knock-knee  and  with  anterior 
bow-leg.  A  more  extended  description  is  hardly  necessary. 
The  deformities  are  usually  of  the  knock-knee  type,  and  they 
may  be  treated  on  the  same  general  plan  that  has  been  outlined 
in  the  description  of  the  less  extreme  distortions. 


CHAPTEE  ,XVII. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 

rEOM  the  orthopedic  standpoint  only  those  diseases  that 
directly  interfere  with  the  fnnction  of  locomotion  or  that  canse 
deformity  and  for  which  local  treatment  is  of  benefit  are  of 
special  interest.  Even  this  limited  class  is  not  often  seen  in  the 
early  or  progressive  stage,  and  it  is  rather  with  the  effects  of  a 
disease  that  is  no  longer  present  than  with  the  disease  itself 
that  the  orthopedic  surgeon  is  especially  concerned. 

The  relative  importance  of  this  branch  of  orthopedic  work 
may  be  illustrated  by  the  statistics  of  the  Hospital  for  Kui3tured 
and  Crippled.  In  the  year  1909,  7296  new  patients  were  ex- 
amined in  the  out-patient  department.  In  1114  of  these  the 
nervous  system  was  involved. 

Anterior  poliomyelitis  furnished  507,  about  46  per  cent,  of 
the  total  number.  In  293  or  22  per  cent,  the  cerebrum  was  in- 
volved. 

ACUTE    ANTERIOR    POLIOMYELITIS. 

Synonym. — Infantile  paralysis. 

Anterior  poliomyelitis  is  an  acute  infectious  disease  of  the 
spinal  cord.  The  cerebrospinal  fluid  and  pia  mater  are  first 
involved.  It  then  extends  to  anterior  horns  of  gray  matter 
which  are  supplied  by  the  largest  and  most  numerous  vessels.^ 
The  inflammation  extends  along  the  cord,  sometimes  involving 
the  brain  and  medulla,  usually  most  intense  at  the  cervical  and 
lumbar  enlargements,  the  process  following  the  blood  vessels 
closely,  and  although  most  marked  in  the  gray  matter  it  is  not 
confined  exclusively  to  it. 

The  minute  changes  in  the  cord  are  characteristic  of  inflam- 
mation, distended  bloodvessels,  minute  hemorrhages,  infiltrat- 
ing leukocytes,  and  serum.  In  the  early  stage  the  motor  cells 
become  cloudy  in  appearance,  later  they  are  swollen  and  lose 
their  distinct  outlines.  The  degenerative  changes  affect  both  the 
cells  and  neuroglia ;  the  affected  gray  matter  shrinks  and  the 
nerve  fibres  atrophy,  and  the  cord  becomes  distinctly  smaller 
at  the  seat  of  the  disease.  When  the  motor  conductivity  of 
'  Harbitz  and  Sheel,  J.  Am.  Med.  Assn.,  Oct.  26,  1907. 
624 


DISEASES   OF   TEE  NEBVOUS   SYSTEM. 


625 


the  cells  is  cut  off,  the  muscles  which  are  supplied  by  them  are 
paralyzed  and  waste  away.  The  circulation  in  the  affected  parts 
is  impaired,  contractions  and  distortions  appear,  and  growth 
is  retarded. 

Etiology. — The  etiology  of  the  disease  is  obscure.  Exposure 
to  heat,  sudden  chilling  of  the  body,  overfatigue,  injury  and  the 
like  are  thought  to  be  predisposing  causes.  The  direct  cause  of 
inflammatory  disease  of  the  cord  is  infection,  apparently  through 
the  gastrointestinal  tract,  possibly  by  the  nasal  passages.  The 
specific  character  of  the  infection  is  still  undetermined.  Ap- 
parently it  belongs  to  the  class  of  minute  and  filterable  viruses.-^ 

The  disease  affects  the  sexes  in  nearly  equal  numbers,  and 
those  in  perfect  health  as  often  as  those  whose  resistance  is  en- 
feebled. It  sometimes  occurs  in  epidemics,  and  there  are  in- 
stances in  which  several  members  of  the  same  family  have  been 
affected,  but  usually  the  cases  are  isolated. 

Age.. — Acute  anterior  poliomyelitis  is  essentially  a  disease  of 
infancy,  although  it  is  not  uncommon  in  adolescence  or  even 
early  adult  life.  This  is  illustrated  by  the  statistics  tabulated 
by  Starr^  and  Lovett.^ 


OS 

u 

S3 

u 

(0 

i 

03 

-g 

-d 

13 

ja 

ja 

J3 

J3 

^ 

ja 

Ji 

'"' 

Tj( 

U5 

to 

i> 

00 

en 

s 

Starr 

118 

214 

140 

52 

38 

12 

7 

14 

8 

6 

12 

Lovett 

78 

150 

128 

65 
or  71  p 

40 
er  cent 

36 

18 

13 

8 

7 

12 

V 

828 

in  first  3  years  of  life 

196 

364 

268 

117 

78 

48       25       27     16 

13 

It  is  far  more  common  during  the  warm  months  than  at  other 
seasons,  as  is  illustrated  by  the  table. ^ 

January    16 

February    9 

March     25 

April     14 

May     24 

June    62  /- 

July    133 

August    1591 

September    112  [ 

October     81 

November     40 

December    4 


465,  or  68  per  cent., 
during  the  four 
months,  June  to 
September. 


40 


679 

^Flexner  and  Lewis,  J.  Am.  Med.  Assn.,  Dec.  18,  1909. 
-Loomis  and  Thompson's  System  of  Practical  Medicine. 
^  Loc.  cit. 
*  J.  Am.  Med.  Assn.,  Nov.  14,  1908. 


626  OBTHOPEDIC  SUBGEBY.    ■ 

In  epidemics  tlie  mortality  is  fairly  high,  as  is  instanced  by 
the  statistics  of  Wickman  of  1025  cases.  Of  these  patients  145 
died  directly  from  the  disease,  12.2  jDer  cent.  In  five  years 
1905-1909,  7103  cases  were  reported  in  'New  York  City  with 
538  deaths,  7.4  per  cent.  In  epidemics  there  are  many  abortive 
cases  in  the  sense  that  joaralysis  does  not  follow  as  in  14  per 
cent,  of  the  cases  reported  by  Wickman  and  there  are  others  in 
which  the  paralysis  is  transitory.-^ 

Distribution  of  the  Paralysis.- — The  lower  extremities  are  far 
more  often  paralyzed  than  the  .npper.  In  1001  of  1224  cases, 
tabulated  by  Starr  and  Lovett,  the  paralysis  was  limited  to  the 
lower  extremities,  as  contrasted  with  63  cases  in  which  the 
upper  extremities  were  alone  involved.  • 

Seelig- 

Duchenne.    muller..  Sinkler.  Starr.  Lovett.  Total. 

Both  legs    9  14  107  40  130  300 

Eight   leg    25  15  63  20  216  339 

Left   leg    7  27  62  27  239  362 

Eight   arm    5  9  5  7  5  31 

Left    arm    5  4  8  4  5  26- 

Both   arms    .  . 2  1  1  2  0  6 

All    extremities    5  2  35  5  3  50 

Arm  and  leg  same  side.  .1  2  26  4  15   .  48 

Arm  and  leg  oppo.  sides.   2  1  "14  7  '    15 

Trunk    1  0  22  3  6  32 

Three   extremities    0  0  10  2  2  .       15 

62  75  240  118  628  1,224 

In  general  it  may  be  stated  that  the  upper  arm  muscles  are 
more  often  involved  than  the  lower.  The  anterior  thigh  muscles 
far  more  often  than  the  posterior.  The  anterior  leg  group  far 
more  often  than  the  posterior  and  the  adductor  muscles  of  the 
foot  than  the  abductor.  The  tensor  vaginae  femoris  muscle  and 
the  short  flexors  of  the  toes  most  often  retain  power  when  the 
paralysis  is  extensive. 

Symptoms. — The  disease  and  its  effects  may  be  divided  into 
several  stages :  . 

1.  The  stage  of  onset.  This  is  usually  attended  by  constitu- 
tional symptoms,  by  fever  and  headache;  by  vomiting  and 
intestinal  disturbance,  and  occasionally  by  severe  pain  explained 
according  to  Flexner  by  involvement  of  the  intervertebral  ganglia. 
In  most  instances  the  elevation  of  the  temperature  is  not  extreme, 
nor  is  the  constitutional  disturbance  severe,  and  but  for  the 
f)aralysis  the  attack  would  be  considered  as  one  of  the  ordinary 
illnesses  so  common  in  childhood.  In  some  cases,  however,  the 
*  Zeitsch.  f .  klin.  Med.,  No.  63,  1907. 


DISEASES   OF   THE  NERVOUS   SYSTEM.  627 

fever  is  high,  and  ihere  may  be  convulsions,  delirium,  and  pro- 
longed unconsciousness,  while  in  others  there  may  be  no  pre- 
monitory symptoms  whatever;  the  child,  apparently  well  at 
night,  wakens  in  the  morning  paralyzed. 

In  many  instances  the  weakness  or  paralysis  caused  by  an- 
terior poliomyelitis  of  a  mild  type  is  not  discovered  until  the 
child  begins  to  walk,  when  the  awkward  gait  or  limp,  or  the  dis- 
tortion of  a  foot,  may  make  it  evident. 

In  a  few  hours  or  a  few  days  after  the  first  symptoms  of  the 
disease  the  paralysis  appears ;  its  area  corresponding  in  some 
degree  to  the  severity  of  the  symptoms  may  extend  slowly  after 
it  is  recognized,  or  its  extreme  limit  may  be  reached  at  once. 
This  original  paralysis  is  always  greater  than  that  which  finally 
persists.  The  duration  of  the  first  stage  may  be  from  a  few 
hours  to  a  week. 

2.  Then  follows  a  stationary  period,  lasting  from  a  week  to 
a  month;  the  constitutional  symptoms  cease  but  the  paralysis 
remains. 

3.  This  is  succeeded  by  the  stage  of  partial  recovery,  lasting 
from  one  to  six  months  or  longer.  The  muscles  which  were 
paralyzed  because  of  the  secondary  congestion  and  exudation 
about  the  local  myelitis  recover  their  power  in  whole  or  in  part, 
while  those  muscles  supplied  from  the  area  in  the  cord  in  which 
the  nerve  cells  have  been  destroyed  waste  away.  At  this  time 
the  contractions  and  distortions  in  the  paralyzed  limbs  appear. 

4.  The  chronic  stage.  This  may  be  considered  from  the 
therapeutic  standpoint  to  last  until  adult  age  or  until  the  ulti- 
mate effect  on  the  individual,  due  to  the  retardation  of  the 
growth  and  unbalancing  of  the  mechanical  equilibrium  of  the 
body,  may  be  complete. 

The  sensation  of  the  paralyzed  part  is  not  affected  except  in 
the  extreme  cases.  The  temperature  is  lower  from  the  first.  In 
many  instances  the  limb  is  not  only  cold,  but  it  is  congested  and 
blue.  These  circulatory  disturbances  are  caused  primarily  by 
the  interference  with  the  vasomotor  function,  but  they  are  con- 
firmed later  by  the  atrophy  of  the  muscles  and  by  the  permanent 
contraction  of  the  bloodvessels.  Thus,  in  general,  the  impair- 
ment of  the  circulation  corresponds  to  the  degree  of  the  paraly- 
sis, but  not  absolutely  so.  In  certain  cases  the  paralysis  may  be 
limited  in  extent,  and  yet  the  limb  may  be  cold  and  congested, 
while  in  others  in  which  the  loss  of  power  is  much  greater  the 
temperature  is  but  slightly  lowered  and  the  color  remains  nor- 


628  OETHOPEDIC  SUBGEBT. 

mal.  The  same  is  true  of  retardation  of  growth.  In  most  in- 
stances the  ultimate  shortening  of  the  limb  corresponds  to  the 
degTee  of  the  paralysis  and  consequent  loss  of  function;  but 
occasionally  cases  are  seen  in  ^Yhich  the  growth  is  markedly  re- 
tarded, although  but  few  of  the  muscles  are  paralyzed. 

Diagnosis. — It  is  doubtful  if  the  diagnosis  of  acute  anterior 
poliomyelitis  could  be  made  before  the  stage  of  paralysis.  But 
after  the  paralysis  has  appeared  there  should  be  little  difficulty 
in  interpreting  the  symptoms.  It  is  a  disease  usually  of  acute 
onset,  followed  by  paralysis  of  certain  muscular  groups  or  of 
entire  members.  It  is  a  flaccid  paralysis,  the  reflexes  are  lost, 
the  muscles  no  longer  contract  under  faradism,  and  the  reaction 
of  degeneration  soon  appears ;  the  tissues  waste,  and  the  circu- 
lation is  impaired  in  the  aifected  parts. 

It  is  usual  to  consider  first  in  diiferential  diagnosis  the 
paralyses  of  cerebral  origin,  but  this  is  more  for  the  purpose  of 
calling  attention  to  the  essential  dift'erences  between  the  two 
than  because  they  are  likely  to  be  confounded  by  one  acquainted 
with  the  ordinary  characteristics  of  cerebral  and  spinal  disease. 

Paralysis  of  Cerebral  Origin  in  Childhood. — The  common  form 
is  hemiplegia.  It  usually  follows  convulsions,  and  the  intelli- 
gence may  be  impaired.  The  paralysis  is  not  complete,  nor  is  it 
limited  to  groups  of  muscles;  it  is  rather  powerlessness  or  im- 
pairment of  function,  due  to  loss  of  cerebral  control.  The  reflexes 
are  increased  and  limbs  are  stiffened,  not  flaccid.  The  elec- 
trical reactions  are  not  lost  or  changed  in  quality.  Paralysis 
of  cerebral  origin  may  be  also  paraplegic  or  diplegic  in  its  dis- 
tribution, but  in  these  cases  the  general  characteristics  are  the 
same  as  in  the  hemiplegic  form,  except  that  the  intelligence  is 
more  markedly  affected. 

Other  Forms  of  Spinal  Paralysis. — Transverse  myelitis  is  very 
uncommon  in  childhood.  In  this  disease  the  distribution  is 
equal,  the  reflexes  are  at  first  increased,  and  sensation  as  well 
as  motion  is  lost. 

Pott's  Paraplegia. — In  this  f«jrm  of  paralysis,  also,  the  distri- 
bution is  equal,  the  reflexes  are  increased,  and  the  signs  of  the 
disease  of  the  spine  are  always  present. 

Spastic  Spinal  Paraplegia. — In  this  as  in  the  preceding  form 
the  distribution  is  equal,  and  the  reflexes  are  exaggerated. 

Rheumatism  and  Joint  Disease. — In  orthopedic  practice  an- 
terior poliomyelitis  is  not  often  seen  in  the  stage  of  onset  unless 
pain  is  a  prominent  symptom,  when  the  disease  may  be  mis- 


DISEASES   OF   THE  NEEVOUS   SYSTEM.  629 

taken  for  rheumatism  or  for  some  form  of  joint  disease.  Cases 
of  this  type  are  not  uncommon.  The  muscles  are  sensitive  to 
pressure  and  the  movements  of  the  joints  cause  discomfort.  In 
certain  instances  the  paralysis  may  not  be  apparent  on  the  first 
examination;  when  it  does  appear  the  diagnosis  is,  of  course, 
established;  therefore,  the  characteristics  of  diseases  of  the 
joints  need  not  be  detailed. 

Multiple  Neuritis. — Multiple  neuritis  is  usually  a  sequel  of 
infectious  diseases,  or  of  metallic  poisoning.  In  the  cases  due 
to  metallic  poisoning  with  lead  or  arsenic  the  paralysis  usually 
begins  in  the  extensors  of  the  hands  and  feet,  and  is  symmetrical 
in  its  distribution.  This  is  true,  also,  of  the  localized  forms  of 
paralysis  following  contagious  diseases  in  which  the  dorsal 
flexors  of  the  feet  are  most  often  involved.  In  multiple  neuri- 
tis there  is  usually  local  sensitiveness  lasting  a  longer  time  than 
in  poliomyelitis;  the  paralysis  is  gradual  in  its  onset,  and 
sensation  as  well  as  motion  is  affected. 

Diphtheritic  Paralysis. — Diphtheria  is  the  most  common  cause 
of  general  weakness  terminating  in  paralysis,  but  in  these  cases 
there  is  usually  a  history  of  the  preceding  disease.  The  paraly- 
sis appears  first  in  the  muscles  of  the  throat  and  neck,  and  a 
general  and  increasing  weakness  precedes  for  a  considerable 
interval  the  complete  loss  of  power. 

Weakness.  Pseudoparalysis. — Weakness  caused  by  rhachitis  or 
so-called  pseudoparalysis,  due  to  this  or  to  other  affections,  is 
readily  distinguished  from  actual  paralysis  by  pricking  the 
part  with  a  pin,  when  muscular  contraction  and  movement  of 
the  limb  will  be  evident.  This  test  of  function  is  of  value  iR 
showing  the  distribution  of  actual  paralysis.  Loss  of  power  in: 
the  tibialis  anticus  muscle,  for  example,  causes  valgus  resem- 
bling closely  the  ordinary  valgus  due  to  simple  weakness.  Ini 
simple  weakness  the  child  withdraws  the  foot  from  the  point  of 
the  pin,  and  the  ability  to  move  it  in  all  directions  is  very  evi- 
dent ;  but  if  the  tibialis  anticus  muscle  is  paralyzed  the  foot  is 
always  flexed  in  the  abducted  attitude.  The  same  test  may  be 
made  for  paralysis  of  other  muscles  or  muscular  groups.  It  is, 
a  test  that  is  easily  applied  and  that  is  especially  useful  in  the 
examination  of  young  children. 

Obstetrical  Paralysis. — Paralysis  of  the  arm  due  to  anterior 
poliomyelitis  is  infrequent  as  compared  with  that  of  the  lower 
extremity.  This  form  might  be  mistaken  for  obstetrical  par- 
alysis, but  the  history  of  the  disability  and  its  distribution 
should  make  the  diagnosis  clear. 


630  OBTHOPEDIC  SURGEEY. 

Prognosis. — The  death  rate  varies  from  3—15  j^er  cent,  accord- 
ing to  the  character  of  the  disease.  The  prognosis  as  to  func- 
tion depends  primarily  npon  the  area  of  the  destructive  disease 
of  the  cord,  secondarily  upon  the  treatment  of  the  weakened  or 
disabled  part.  As  has  been  stated,  the  extent  of  the  primary 
paralysis  is  very  much  greater  than  that  which  ultimately  re- 
mains when  the  inflammatory  changes  about  the  diseased  area 
in  the  cord  have  subsided. 

The  Electrical  Test. — During  the  early  stages  of  the  disease 
the  degree  of  final  paralysis  may  be  fairly  estimated  by  the 

Fig.  418. 


Anterior  poliomyelitis.     Extreme  flexion  deformity  at  the  hips,  inducing  quadru- 
pedal locomotion.      (Gibney.) 

electrical  reaction.  Within  a  week  after  the  initial  paralysis 
the  reaction  to  the  faradic  current  in  the  muscles  and  nerves  in 
direct  connection  with  the  diseased  area  is  lessened  and  is  soon 
lost.  If  the  faradic  irritability  is  retained  in  the  paralyzed 
muscles,  or  if  it  is  merely  diminished,  recovery  may  be  pre- 
dicted. The  muscles  which  no  longer  react  to  the  faradic  irri- 
tation may  still  be  made  to  contract  by  the  galvanic  current. 
In  normal  muscles  the  reaction  is  greatest  at  the  closing  of  the 
negative  pole.     In  the  paralyzed  muscles  the  reaction  is  slower. 


DISEASES   OF   TEE   NEBVOUS   SYSTEM.  631 

it  requires  stronger  stimulation,  and  th^  contraction  is  greater 
at  the  closing  of  the  positive  pole.  This  is  known  as  the  reac- 
tion of  degeneration.  The  loss  of  faradic  reaction  and  the 
change  in  the  galvanic  reaction  indicate  that  the  function  of 
the  affected  muscle  is  lost,  although  certain  of  its  fibres  may  in 
time  regain  their  power. 

The  Effects  of  Paralysis  of  Different  Muscles  and  Groups  of 
Muscles  upon  Function. — The  principal  interest  in  anterior  polio- 
myelitis lies  in  its  immediate  and  ultimate  effects  upon  the 
functional  ability  of  the  individual.  These  effects  may  be 
classified  as  deformity  of  the  part  directly  involved  and  the  in- 
fluence of  weakness^,  deformity^  and  loss  of  growth  upon  the 
body  as  a  whole. 

Causes  of  Deformity. — The  deformities  of  anterior  poliomye- 
litis are  caused: 

1.  By  force  of  gravity. 

2.  By  the  unopj)osed  action  of  the  active  muscles. 

3.  By  functional  use. 

All  these  and  other  less  important  causes  of  deformity  are, 
of  course,  "combined  in  most  instances.  The  relative  importance 
of  each  factor  varies,  according  to  the  muscular  group  that  is 
involved,  with  the  age  of  the  patient,  and  with  the  strain  to 
which  the  part  is  subjectecl.  The  influence  of  the  different 
factors  can  be  studied  best  in  the  foot. 

Muscular  Action  and  Gravity. — In  by  far'  the  larger  number  of 
cases,  one  or  more  of  the  dorsal  flexors  of  the  foot  are  involved. 
This  is  illustrated  by  the  statistics  of  acquired  talipes,  tabu- 
lated elsewhere,  the  equinus  type  of  deformity  being  three  times 
as  common  as  the  calcaneus  form. 

If  the  anterior  muscles  are  paralyzed  before  the  walking  age, 
the  foot  drops  under  the  influence  of  the  force  of  gravity  into 
the  attitude  of  equinus.  If  this  attitude  is  allowed  to  persist, 
the  muscles  on  the  posterior  aspect  of  the  limb,  accommodating 
themselves  to  the  habitual  attitude  become  structurally  shortened. 
In  such  cases  the  equinus  deformity  is  caused  by  the  force  of 
gravity;  it  is  increased  by  muscular  action  and  it  is  fixed  by 
muscular  adaptation.  That  deformity  is  not  caused  directly 
by  must3ular  action  is  shown  by  the  fact  that  it  may  be  pre- 
vented by  stimulating  the  paralyzed  muscles  from  time  to  time 
with  galvanism,  or  even  by  systematic  passive  movements  to  the 
limit  of  dorsal  flexion.  Deformity  is  thus  prevented,  not  by 
opposing  muscular  action,  but  by  stretching  the  active  muscles 


632 


OBTROPEDIC  SVEGEEY. 


to  the  full  limit  and  tlius  preventing  muscular  adaptation  and 
structural  change.  In  the  instance  cited  gravity  and  muscular 
activity  are  combined  in  the  production  of  equinus,  but  in  other 
instances  gravity  and  muscular  power  may  be  opposed  to  one 

another.    If,  for  example,  the 
Fig.  419.  calf  muscle  is  paralyzed  while 

the  anterior  group  retains  its 
power,  the  deformity  of  cal- 
caneus does  not  appear  until 
the  child  begins  to  use  the 
foot,  when  the  peculiar  help- 
lessness calls  attention  to  the 
disability,  if  the  diagnosis 
has  not  been  made  before. 
Thus  it  is  that  equinus  may 
be  present  when  the  child  is 
still  in  arms,  while  the  op- 
posite deformity  develops 
much  more  slowly. 

Habitual     Posture There 

are  other  cases  in  which  every 
vestige  of  muscular  power  is 
lost  and  in  which  the  foot 
dangles.  In  this  class  there 
is  no  functional  activity  or 
tonic  contraction  of  the  mus- 
cles ;  consequently  deformity 
is  slow  in  making  its  appear- 
ance ;  it  is  not  often  extreme, 
and  it  becomes  fixed  only  by 
the  structural  shortening  of 
inactive  tissues,  the  liga- 
ments, fascise,  and  the  atro- 
phied muscles.  There  are,  of 
course,  other  causes  for  habit- 
ual posture  than  the  force 
of  gravity  and  muscular  ac- 
tion, such  as,  for  example,  the  position  of  convenience  in 
which  a  weak  or  disabled  part  might  be  placed,  but  such  causes 
of  deformity  may  be  considered  as  instances  of  functional  use 
or  rather  of  adaptation  to  local  weakness. 


Anterior  poliomyelitis.  After  seven 
years.  Showing  atrophy  and  slight  lat- 
eral curvature  of  the  spine  ;  two  and  a 
quarter  inches  of  shortening. 


DISEASES   OF   TEE   NEBVOUS   SYSTEM.  633 

Functional  Use  as  a  Cause  of  Deformity. — Thus  far  the  force  of 
gravity,  iinbalancecl  muscular  power,  and  the  structural  changes 
in  the  tissues  have  been  considered  in  the  etiology  of  deformity 
as  it  might  develop  in  infanc}'.  When,  however,  the  patient 
stands  and  walks,  existing  deformities  are  exaggerated  and  con- 
firmed by  the  weight  of  the  body  falling  on  the  unbalanced 
part,  and  by  the  action  of  the  muscles  in  the  attempt  to  supply 
the  function  of  those  that  are  paralyzed.  Thus  it  is  that  the 
deformity  develops  far  more  rapidly  when  a  fair  amount  of 
muscular  power  remains  than  whenit  is  completely  lost.  (See 
Talipes.) 

Subluxation. — Aside  from  the  distortions  due  to  the  cases  that 
have  been  mentioned,  there  are  others  induced  simply  "by  weak- 
ness; for  example,  laxity  of  ligaments  and  the  failure  of  mus- 
cular support  may  permit  distortion  of  a  limb  and  subluxation 
or  even  displacement  at  a  joint  (Figs.  420  and  421).  Complete 
dis23lacement  is  uncommon,  and  occurs  practically  only  at  the 
hip.  In  such  cases  there  is  usually  flexion  deformity  of  the 
limb,  the  femur  being  suspended  by  the  contracted  tissues  at- 
tached to  the  anterior  superior  spine.  This  unyielding  band 
forms  a  fulcrum  by  means  of  which  force  applied  at  the  knee 
may  cause  sudden  displacement  of  the  head  of  the  femur  inward 
or  upward  and  backward. 

Deformities  of  the  Upper  Extremity, — Deformities  caused  by 
paralysis  of  the  muscles  of  the  shoulder  are  usually  slight  be- 
cause the  part  is  not  subjected  to  the  strain  of  weight  bearing, 
and  because  the  force  of  gravity  is  opposed  to  muscular  con- 
traction. In  these  cases  the  loss  of  support  and  the  tension  on 
the  capsule  allow  a  considerable  separation  of  the  joint  sur- 
faces so  that  the  atrophied  head  of  the  humerus  may  be  dis- 
placed forward  or  backward ;  but  there  is  not  often  fixed  dis- 
placement, and  consequently  persistent  distortion  due  to  this 
cause  is  unusual. 

Paralysis  of  the  muscles  of  the  forearm  and  of  the  hand  is 
followed  after  a  time  by  deformity  of  the  fingers,  caused  pri- 
marily by  unopposed  muscular  action,  secondarily  by  accom- 
modation and  atrophy. 

Deformities  of  the  Neck. — Paralysis  of  one  or  more  of  the 
muscles  of  the  neck  may  induce  a  paralytic  torticollis.  This 
is,  however,  uncommon. 

Deformities  of  the  Trunk. — Paralysis  of  the  muscles  of  the 
trunk  mav  induce  distortion  and  extreme  lateral  curvature  of 


634 


OBTHOPEDIC  SUEGEEY. 


the  spine.  This  curvature  is  not  usually  caused,  as  might  at 
first  appear,  by  contraction  of  the  active  muscles  and  thus  a 
bending  of  the  trunk  with  a  convexity  toward  the  weaker  side. 
As  a  rule,  the  curvature  is,  as  a  whole,  in  the  opposite  direc- 
tion.    This  is  explained  by  the  fact  that  if  the  paralysis  is 

Fig.  420. 


Anterior  poliomyelitis,  causing  genu  recurvatum.      (See  Fig.  421.) 


limited  to  one  side  and  is  extensive  enough  to  cause  distortion 
of  the  trunk,  the  muscles  of  respiration  being  involved,  the  chest 
wall  becomes  inactive  and  collapses.  In  compensation  the  oppo- 
site side  of  the  thorax  increases  in  volume  and  lung  capacity 
and  the  weak,  atrophied,  and  sunken  side  is  drawn  toward  it. 
The  same  effect  is  observed  when  the  arm  and  the  shoulder 


DISEASES   OF   THE   NEEVOUS   SYSTEM.  635 

muscles  are  paralyzed,  the  spine  bending  toward  the  side  that 
is  still  active. 

Paralysis  of  the  posterior  group  of  nmscles,  if  extreme,  may 
induce  kyphosis.  Paralysis  of  the  muscles  of  the  abdomen  may 
cause  lordosis,  but  in  this  group  of  cases  the  lower  extremities 
are  usually  involved,  and  the  secondary  distortions  due  to  pos- 
ture and  to  functional  use  mask  the  direct  effect  of  the  paraly- 
sis of  the  muscles  of  the  trunk.  And,  again,  the  overuse  of  the 
arm  muscles  in  patients  whose  lower  extremities  are  paralyzed, 
and  the  suspension  of  the  body  on  crutches  in  walking,  modify 
the  ultimate  effects  in  those  cases  in  w^hich  the  paralysis  is 
widespread  in  its  area.     (See  Lateral  Curvature.) 

Retardation  of  Growth  and  Secondary  Deformities. — The  effects 
of  anterior  poliomyelitis  are  not  limited  to  the  paralysis  and  to 
atrophy  of  the  muscles,  but  all  the  component  tissues  of  the 
affected  limb  are  involved  as  well.  The  bones  become  relatively 
atrophied,  and  their  growth  is  retarded  to  a  degree  fairly  pro- 
portionate to  the  extent  of  the  paralysis  and  to  the  functional 
disability  that  has  resulted.  As  has  been  stated,  retardation  of 
growth  does  not  always  correspond  to  the  degree  of  paralysis. 
In  some  instances  paralysis  of  a  single  muscle,  which  does  not 
seriously  compromise  the  function  of  the  j)art,  is  accompanied 
by  greater  shortening  of  the  limb  than  in  other  cases  in  which 
the  paralysis  is  far  more  extensive.  Thus  it  luay  be  inferred 
that  certain  cells  in  the  spinal  cord  are  especially  concerned  in 
the  growth  and  nutrition  of  the  bones  and  that  interference  with 
the  function  of  these  cells  may  not  correspond  absolutely  to  the 
extent  of  the  destructive  process.  However  this  may  be,  it  is 
certain  that  atrophy  and  retardation  of  growth  are  much  greater 
when  a  limb  is  not  used  than  when  by  the  aid  of  apparatus  it 
has  been  enabled  to  carry  out,  in  part  at  least,  its  proper  func- 
tion. It  is  evident,  also,  that  retardation, of  growth  will  be  more 
marked  during  the  period  of  rapid  development;  thus,  the 
younger  the  patient  the  gTeater  should  be  the  ultimate  inequal- 
ity of  the  limbs. 

Petahdatigjst  of  Growth. — The  ultimate  shortening  varies 
from  one  to  three  inches.  In  the  slighter  degrees  of  paralysis 
affecting  the  leg  the  sbortening  may  be  less  than  an  inch,  but 
when  the  thigh  muscles  are  paralyzed  also  it  may  be  much  more 
(Fig.  419).  This  inequality  is  usually  very  evident  in  the  size 
of  the  two  feet. 

When  both  limbs  are  paralyzed,  so  that  locomotion  is  very 


636  OBTHOPEDIC  SUBGEBY. 

seriously  interfered  with,  the  retardation  of  growth  is  especially 
marked,  and  the  contrast  between  the  trnnk  of  the  patient  and 
the  attenuated  lower  extremities  is  very  striking. 

Fig.  421. 


Anterior  poliomyelitis.     Paralysis  of  muscles  at  the  hip  allows  subluxation  of  the 
femur.     The  same  patient  as  in  Fig.  420. 

CoMPEJfSATOEY  DisTOETio]srs. — Secondary  deformities  must 
include,  besides  those  already  mentioned,  the  compensatory  dis- 
tortions of  the  trunk  that  may  follow  paralysis  of  the  limbs. 
Thus  a  short  leg  might  cause  a  lateral  curvature  of  the  spine, 
or  great  flexion  contraction  of  the  thigh  might  induce  abnormal 
lordosis.  As  a  matter  of  fact,  the  final  effects  of  disabilities  of 
this  character  are  very  complex,  and  are  influenced  by  many 
factors  of  which  only  a  general  indication  is  practicable. 

Treatment. — The  treatment  of  the  acute  stage  of  anterior 
poliomyelitis  is  symptomatic.  If  the  diagnosis  has  been  made^ 
such  measures  as  would  tend  to  relieve  the  congestion  about  the 
diseased  area  should  be  employed;  cathartics,  sedatives,  and 
counter-irritation  of  the  spine,  for  example;  the  first  indica- 
tion being  free  catharsis  and  thecleansingof  the  throat  and  nasal 
passages.  Vaccine  therapy  is  still  in  the  experimental  stage. 
During  the  active  stage  complete  rest  is  indicated,  if  feasible 
on  a  stretcher  frame.  In  cases  in  which  the  paralysis  is  wide- 
spread and  in  which  movement  of  the  limb  causes  discom- 
fort a  single  or  double  long  spica  plaster  splint  may  be  used 
to  support  the  spine  and  extremities.  When  the  acute  symp- 
toms have  subsided  local  treatment  to  maintain  as  far  as  pos- 
sible the  nutrition  of  the  muscles,  to  prevent  deformity  and 
to  relieve  the  strain  upon  the  weakened  tissues,  is  indicated. 
The  nutrition  of  the  parts  may  be  improved  by  massage,  by 
muscle-beating,  by  the  direct  application  of  heat  to  the  cold 


DISEASES   OF   THE   NERVOUS   SYSTEM.  637 

extremities,  and  bj  the  use  of  galvanism,  as  long  as  it  will  in- 
duce contraction  of  the  paralyzed  muscles. 

Deformity  may  be  prevented  by  moving  each  joint  to  the 
limit  of  the  range  of  motion  in  all  directions  several  times  a 
day,  and  by  supporting  the  limb  with  simple  apparatus.  De- 
formity in  those  parts  in  which  it  is  favored  by  muscular  action 
and  by  the  force  of  gravity  appears  much  more  rapidly  than  is 
geuerally  supposed.  The  indications  of  equinus,  for  example, 
are  apparent  within  a  few  weeks  after  paralysis  of  the  anterior 
muscles  of  the  leg.  The  first  indication  of  such  deformity  in 
this  class  is  the  discouifort  caused  by  passively  moving  the  foot 
toward  dorsal  flexion.  This  limitation  of  the  range  of  motion 
rapidly  increases,  and  as  it  increases  it  is  confirmed  by  muscu- 
lar adaptation  and  finally  by  structural  shortening. 

The  Principles  of  Mechanical  Treatment. — The  object  of  a  brace 
is  to  prevent  the  deformity  due  to  weakness  and  to  utilize  the 
muscular  power  that  remains,  so  that  the  disabled  member  may 
carry  out  its  function.  As  each  muscle  has  an  essential  func- 
tion the  paralysis  of  any  one  must  be  followed  by  a  certain  dis- 
ability and  usually  by  deformity.  Muscles  vary  in  importance 
as  they  do  in  strength,  and  the  ultimate  disability  caused  by 
paralysis  may  be  predicted  very  accurately  by  one  who  is 
familiar  with  this  function. 

Paralysis  of  the  Ajstteeioe  Muscles  of  the  Leg. — Par- 
alysis of  the  anterior  leg  group  causes  the  so-called  steppage 
gait;  the  toes  drag  on  the  floor  when  the  limb  is  swung  forward, 
and  this  necessitates  an  awkward  lifting  of  the  knee.  The  result 
of  such  paralysis  is  equinus.  Slight  equinus  has  a  tendency  to 
throw  the  knee  backward,  "  recurvatum,"  in  oTder  that  the 
patient  may  place  the  entire  sole  on  the  ground.  More  marked 
equinus  obliges  the  patient  to  bear  the  weight  entirely  on  the 
front  of  the  foot,  and  causes  flexion  both  at  the  knee  and  hip. 
If  but  one  of  the  muscles  of  the  anterior  group  is  paralyzed  the 
tendency  to  equinus  is  in  so  far  lessened,  but  there  is  an  inclina- 
tion to  lateral  distortion.  Paralysis  of  the  anterior  muscles 
causes  an  awkward  gait  and  often  deformity,  but  the  propelling 
force  of  the  limb  remains.  The  indication  for  support  is 
simple,  to  prevent  the  foot  from  dropping  to  the  extent  that 
incommodes  the  patient,  or  practically  to  hold  the  foot  at  a  right 
angle  with  the  leg. 

Paralysis  of  the  Postekior  Muscles  of  the  Leg. — If, 
on  the  other  hand,  the  calf  muscle  is  paralyzed  the  resistance  of 


638 


OETHOPEDIC  SUBGEEY. 


the  foot  is  lost  and  it  is  simj^ly  dorsiflexed  Avheii  weight  is 
thrown  npon  it..  Thns  the  brace  must  be  arranged  to  prevent 
dorsal  flexion,  and  it  must  be  strong  enough  to  support  the  strain 
■which  is  transmitted  from  the  foot-j^late  of  the  brace  to  the 
front  of  the  leg.  The  various  weaknesses  and  deformities  of 
the  foot  and  the  means  of  treating  them  are  described  at  leng-th 
elsewhere.     (See  Talipes.) 

Paralysis  of  the  calf  muscle  not  only  affects  the  foot,  but  it 
weakens  the  knee  as  well  and  £:enu  recurvatum  is  often  a  second- 


FiG.  422. 


Fig.  423. 


O^ 


The  Judson  brace  for  paralysis  of  the  quadriceps  extensor  muscle  in  connection 
with  deformity  of  the  foot. 


ary  effect.  In  many  instances,  therefore,  it  will  lie  necessary 
to  support  the  knee  as  well  as  the  ankle  dtiring  the  earlier  stages 
of  the  treatment. 

Paralysis  of  the  Thigh  Muscles. — Paralysis  of  the  quad- 
riceps extensor  muscle  causes  primarily  a  peculiar  gait.  The 
patient,  unable  to  extend  the  leg  upon  the  thigh,  throws  or 
swings  it  forward,  then  locks  the  joint  by  direct  contact  of  the 
bones  and  by  the  resistance  of  the  posterior  tissues,  by  inclining 
the  body  somewhat  forward  as  the  weight  falls  upon  it.  In  this 
manner,  again,  the  knee  may  be  overextended.  Or  if  extension 
is  checked  by  shortening  of  the  tissues,  induced,  for  example, 


DISEASES   OF   THE  NERVOUS   SYSTEM. 


639 


by  habitual  assumption  of  the  sitting  posture,  the  patient  being 
unable  to  lock  the  joint  effectivelj  by  complete  contact  of  the 
bones,  often  trips  and  falls  because  of  the  insecurity  of  the  sup- 


FiG.  424. 


Fig.  425. 


a:^ 


A  brace  for  complete  paralysis  of 
the  limb,  showing  a  form  of  lock  at 
the  knee  and  a  limited  joint  at  the 
ankle. 


Anterior  poliomyelitis.  Paralysis  of 
the  anterior  and  posterior  muscles.  Re- 
curvation  of   the  right  knee. 


port.  When  in  the  normal  subject  the  weight  is  borne  upon  one 
limb  in  the  attitude  of  rest,  in  which  the  muscles  are  thrown  out 
of  action,  the  knee-joint  is  locked,  but  the  insecurity  of  this  sup- 
port is  illustrated  by  the  school-boy's  trick  of  striking  the  back 


640  OETHOPEDIC  SUBGEET. 

of  the  kiiee  with  the  hand,  when,  the  muscles  being  taken  una-' 
wares,  the  person  falls  to  the  ground.     This  insecurity  is  con- 
stant when  the  extensor  of  the  leg  is  paralyzed.    For  this  reason 
the  patient  often  uses  the  hand  to  steady  the  limb  in  locomotion. 
Paralysis  limited  to  the  quadriceps  extensor  muscle  is,  how- 
ever, unusual.     In  almost  all  cases  some  of  the  leg  muscles  are 
involved  also,  and  the  brace  usually  must  serve  to  support  the 
foot  as  well  as  the  knee.     In  its  ordinary  form  such  a  brace  is 
constructed  of  two  lateral  upright  bars,  reaching  nearly  to  the 
pubes  on  the  inner  and  to  the  trochanter  on  the  outer  side, 
joined  to  one  another  by  bands  passing  beneath  the  thigh  and 
the  calf,  and  attached  to  a  light  steel  foot-plate.     If  the  dorsal 
flexors  of  the  foot  are  paralyzed  the  ankle-joint  is  arranged  to 
allow  dorsal  flexion,  but  to  prevent  extension  beyond  the  right 
angle.    If  the  calf  muscle  is  paralyzed  a  reverse  catch  is  used,  or 
the  uprights  are  attached  directly  to  the  foot-plate  without  a 
joint  (Fig.  423),  or  the  so-called  limited  joint,  allowing  only 
a  few  degrees  of  motion  in  either  direction,  is  used  (Fig.  424). 
(See  Talipes.)     In  the  treatment  of  young  children  the  joint  is 
also  omitted  at  the  knee,  the  limb  being  firmly  held  in  the  ex- 
tended position  during  the  active  period  (Figs.  423  and  426). 
This  is  of  advantage  because  the  joint  is  the  weakest  part  of  the 
brace  and  it  soon  becomes  loose  under  the  severe  strain  to  which 
it  is  subjected.     In  older  subjects  a  joint  is  arranged  with  a 
spring  catch,  the  brace  being  held  in  the  straight  position  when 
the  patient  is  walking  about,  but  allowing  flexion  when  the 
sitting  posture  is  assumed.      This  is,  of  course,  a  great  con- 
venience (Fig.  424).    In  fitting  the  brace  the  lateral  bars  should 
be  adjusted  to  support  the  limb  without  uncomfortable  pres- 
sure,  and  the   joints   should  be   exactly   opposite   the   normal 
centres  of  motion.     The  thigh  and  leg  bands  should  be  properly 
fitted  to  the  contour  of  the  soft  parts  so  that  half  the  limb  is 
contained    within    them.      These    are    smoothly    covered    with 
leather,  and  the  limb  is  held  in  position  by  leather  bands  that 
complete  the  circumference.     Other  bands  are  applied  across 
the  front  or  back  of  the  limb,  either  to  support  it  or  to  fix  it 
firmly  in  place.     In  the  ordinary  brace  mthout  the  joint  at  the 
knee  there  are  three  anterior  bands,  one  across  the  front  of  the 
thigh,  another  across  the  leg,  and  the  third,  a  wide  knee-cap, 
supports  the  greater  part  of  the  strain  (Fig.  426). 

Paralysis  of  the  Muscles  of  the  Hip. — The  effect  of  par- 
alysis of  the  muscles  about  the  hip  is  difficult  to  describe,  as  in 


DISEASES   OF   THE   NEBVOUS   SYSTEM. 


641 


these  cases  many  other  muscles  are  usually  involved.  If  all 
the  muscles  are  paralyzed  the  thigh  dangles.  This  is,  however, 
very  unusual,  for  the  tensor  vaginse  femoris  almost  always 
retains  its  power  and  it  is  one  of  the  causes  of  flexion  deformity 
which  is  so  often  present  in  cases  of  this  character. 


Fig.  426. 


Brace  for   complete   paralysis   of  the  anterior   muscles   of   the   limb  ;    before   and 

after  covering. 

Paralysis  of  the  iliopsoas  muscle  makes  it  impossible  for  the 
patient  to  flex  the  thigh  directly.  If  the  adductors  are  par- 
alyzed he  must  lift  the  thigh  with  the  hand  when  adduction  is 
desired.  Paralysis  of  the  glutei  is  made  evident  by  the  atrophy 
and  by  the  weakness  of  the  extending  power  of  the  limb. 

The  distribution  of  the  paralysis  of  the  muscles  of  the  hip 
may  be  ascertained  by  placing  the  patient  in  the  recumbent 
posture ;  the  leg  is  then  lifted  from  the  table,  and  by  placing  the 
thigh  in  different  positions  the  ability  of  the  patient  to  move  it 
may  be  tested,  in  older  subjects  by  voluntary  effort,  in  younger 
ones  by  pricking  the  part  slightly  with  a  pin. 
41 


642 


OETHOPEBIC  SUEGERY. 


Fig.  427. 


General  weakness  of  the  muscles  of  the  hip  causes  an  awk- 
ward, insecure  gait,  accompanied  usually  by  outward  rotation 
of  the  limb,  and,  as  has  been  stated,  there  is  almost  always 
accompanying  paralysis  of  other  muscles  of  the  extremity.     In 

such  cases  a  pelvic  band 
must  be  attached  to  the  leg 
brace.  The  pelvic  band  is 
made  of  sheet  steel  of  about 
18  gauge,  two  inches  wide, 
fitted  to  the  pelvis,  which 
it  encircles  midway  be- 
tween the  crest  of  the  ilium 
and  the  trochanter.  At 
this  point  it  is  attached  to 
the  brace  by  a  free  joint 
(Fig.  427).  When  the 
band  is  accurately  adjusted 
and  strapped  firmly  about 
the  pelvis,  the  necessary 
security  is  assured  and  the 
attitude  of  the  limb  in 
walking  can  be  regulated. 
If  greater  support  is  de- 
sired a  perineal  band  may 
be  applied  as  described  in 
the  chapter  on  Disease  of 
the  Hip-joint. 

If  both  limbs  are  par- 
alyzed double  braces  must 
be  used.  If  the  muscles 
of  the  lower  part  of  the 
back  are  much  weakened 
the  pelvic  band  may  be  re- 
placed by  a  corset  or  some 
form  of  back  brace,  For- 
tunatelv  these  eases  are  un- 


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k^^^^^^^^^^B 

Leg  brace,  with  pelvic  band.  Double 
uprights.  No  joint  at  knee.  For  paralysis 
of  the  anterior  thigh  and  leg  muscles. 


common. 

Pakalytic  Scoliosis. — Paralytic  scoliosis  requires  the  sup- 
port of  corsets  or  braces  as  a  rule,  such  as  are  used  in  the  treat- 
ment of  other  forms  of  distortion  of  the  back.  (See  Lateral 
Curvature. ) 

Paralysis  of  the  Arm. — Paralysis  of  the  arm  is  compara- 


DISEASES   OF   THE   NEBVOUS    SYSTEM.  643 

tively  uncommon,  and  mechanical  treatment  is  rarely  de- 
manded. 

In  some  instances  a  shonlder  suj)port  may  be  of  service  or  a 
brace  to  hold  the  arm  at  a  right  angle  if  the  biceps  is  paralyzed. 
If  the  muscles  of  the  scapula  retain  their  power  the  operation 
of  arthrodesis  with  supplementary  shortening  of  the  capsule 
might  be  of  service  in  fixing  the  dangling  joint  in  older  subjects, 
and  the  same  operation  might  be  useful  at  the  elbow.  It  is,  of 
course,  evident  that  one  of  the  lower  extremities,  although  hope- 
lessly weakened,  may  be  braced  so  that  it  may  serve  as  a  simple 
prop  to  bear  weight,  but  as  the  function  of  the  arm  is  quite 
different,  extensive  paralysis  of  its  muscles  makes  it  practically 
useless  to  the  individual. 

Operative  Treatment. — The  Rebuction  of  Deformity. — In 
a  large  proportion  of  the  cases  of  anterior  poliomyelitis  the 
patients  are  not  seen  by  the  orthopedic  surgeon  until  months  or 
years  have  elapsed  since  the  original  attack.  They  are  then 
brought  for  treatment  because  of  secondary  deformity,  often  of 
an  extreme  degree.  At  least  half  of  the  cases  of  talipes  are  due 
to  this  cause,  and  with  the  deformity  of  the  foot  are  often  com- 
bined other  distortions  varying  in  degree  with  the  extent  of  the 
paralysis.  Many  of  the  patients  hobble  about  on  a  distorted 
foot,  others  use  crutches,  and  in  a  smaller  number  the  only 
method  of  locomotion  is  creeping  on  all-fours.  In  the  cases  in 
which  the  patient  has  habitually  used  crutches  allowing  the 
paralyzed  limb  to  '' dangle,"  there  is  usually  marked  flexion  at 
the  three  joints.  The  thigh  is  flexed  upon  the  pelvis,  the  leg  is 
flexed  uj)on  the  thigh,  and  the  foot  hangs  downward  and  inward 
(plantar  flexed)  in  an  attitude  of  equinovarus. 

However  extreme  the  paralysis  of  a  lower  extremity  may  be, 
the  limb  may  be  made  useful  as  a  prop  when  properly  braced; 
this  prop  will  enable  the  patient  to  dispense  v^th  the  use  .of 
crutches  and  thus  free  the  arms  from  unnecessary  work.  Even 
if  both  limbs  are  paralyzed  they  may  at  least  serve  as  supports 
to  enable  the  patient  to  stand  erect  and  to  propel  himself  with 
the  aid  of  crutches.  If  a  limb  has  been  disused  for  a  lone;  time, 
the  atrophy  is  usually  extreme,  the  bones  are  fragile,  and  the 
growth  has  been  greatly  retarded  as  compared  with  those  limbs 
in  which  deformity  has  been  prevented  and  in  which  the  weight 
of  the  body  has  been  sustained  in  functional  use.  In  this  class 
of  cases  the  first  step  must  be  the  reduction  of  deformity;  the 
foot  must  be  brought  to  a  right  angle  with  the  leg,  the  limb 


644  OBTHOFEDIC  SUBGEBY. 

must  be  brought  to  the  straight  line,  and  the  flexion  at  the  hip 
must  be  overcome  in  order  to  enable  the  patient  to  stand  erect 
without  bending  the  spine  forward  in  compensatory  lordosis. 

Acquired  deformity  of  the  foot  is  far  less  resistant  than  is 
the  congenital  form,  and  by  tenotomy  and  the  proper  applica- 
tion of  force  it  may  be  readily  straightened,  usually  at  one 
sitting. 

The  flexion  contraction  at  the  knee  may  be  overcome  also  by 
careful  and  j)ersistent  manual  stretching  combined,  if  neces- 
sary, with  division  of  the  Contracted  tissues  on  the  posterior 
aspect  of  the  joint.     (See  reverse  leverage,  Fig.  295.) 

The  flexion  deformity  at  the  hip  is  usually  fixed  by  the  con- 
traction of  the  tissues  about  the  anterior  superior  spine  of  the 
ilium,  including  the  tensor  vaginas  femoris  muscle,  which  is 
rarely  paralyzed.  These  tissues,  together  with  the  fascia,  may 
be  divided  subcutaneously,  or  by  open  incision  if  necessary; 
after  which  the  deformity  may  be  reduced  by  gradual  forcible 
extension  of  the  thigh  while  the  pelvis  is  fixed  by  flexing  the 
other  limb  upon  the  body.  When  the  contraction  deformities 
are  overcome  lateral  deviation  at  the  knee  is  corrected,  if  it  be 
present,  in  the  same  manner,  and  the  bony  points  having  been 
carefully  protected  by  padding  a  long  spica  plaster  bandage  is 
applied  to  fix  the  limb. 

It  is  of  interest  to  note  in  this  connection  that  fat  embolism 
is  a  complication  to  be  considered  in  operations  on  bones  con- 
taining an  abnormal  proportion  of  fat.  In  1000  operations  of 
this  class  collected  by  Renier^  there  were  10  cases  of  fat  embol- 
ism with  four  deaths.  The  use  of  the  Esmarch  bandage  during 
the  operation  followed  by  complete  fixation  of  the  part  should 
prevent  this  complication. 

The  lesser  degrees  of  deformity  may  be  reduced  by  other 
means,  for  example,  by  repeated  applications  of  plaster  band- 
ages under  slight  corrective  force,  or  by  manipulation,  or  by 
braces  and  bandaging. 

Paralytic  knock-knee  may  be  corrected  by  the  Thomas  knock- 
knee  brace,  and  this  brace  when  attached  to  a  pelvic  band  is  a 
useful  form  of  support  in  the  routine  treatment  of  paralysis  of 
the  leg  (Fig.  407). 

The  Thomas  caliper  knee  brace  is  another  cheap  and  useful 
support.  It  is  of  special  service  when  there  is  flexion  or  lateral 
deformity  of  the  limb  (Fig.  302). 

1  Munch,  mecl.  Wochen.,  Nov.,  1907. 


DISEASES   OF   THE  NERVOUS   SYSTEM. 


645 


When  distortion  has  been  overcome  and  when  functional  use 
has  been  made  possible  by  proper  support,  the  development  of 
active  muscles  which  have  been  thrown  out  of  use  bj  the  distor- 
tions, and  of  those  in  which  part  of  the  muscular  substance  has 
been  retained,  is  surprising.     In  many  of  these  cases  the  distor- 

FiG.  428. 


Paralysis  of  the  left  deltoid  muscle,  showing  the  elevation  of  the  shoulder  when 
the  patient  attempts  to  abduct  the  arm.      (See  Fig.  429.) 

tions  which  develop  during  the  temporary  paralysis  have  alone 
prevented  recovery,  and  this  latent  power  may  be  revived  even 
after  years  of  disuse.  Thus  in  many  instances  prognosis  is 
impossible  until  the  deformities  have  been  corrected  and  until 
the  limb,  properly  supported,  has  been  enabled  to  resume  its 
function. 

Tendon  Teansplantation. — This  operation  is  best  adapted 
to  the  treatment  of  distortions  of  the  foot  caused  by  paralysis  of 
the  muscles  of  the  leg,  and  the  procedure  is  described  at  length 
in  that  section. 

Hoffa's  Operation  foe  Paealysis  of  the  Deltoid 
Muscle. — One  of  the  most  useful  operations  of  this  class  is  the 


646 


OBTROPEDIC  SUBGEEY. 


transplantation  of  the  trapezius  muscle  for  paralysis  of  the 
deltoid.  In  cases  of  this  class  there  is  disabling  laxity  or  even 
subluxation  at  the  articulation,  and  the  exaggerted  elevation  of 
the  shoulder  when  the  patient  attempts  to  raise  the  arm  makes 
the  disability  very  noticeable  (Fig.  428). 

A  broad  flap  of  skin,  its  convexity  over  the  upper  quarter  of 
the  deltoid  muscle,  is  raised,  exposing  the  trapezius.     This  is 

Fig.  429. 


Illustrating  the  improvement  in  the  range  of  abduction  obtained  by  transplanta- 
tion of  the  trapezius  muscle.     The  line  of  the  incision  is  shown. 

thoroughly  separated  from  its  attachment  to  the  spine  of  the 
scapula  and  to  the  clavicle.  The  arm  is  then  abducted  and  the 
flap  of  muscle,  made  tense,  is  sewed  with  numerous  silk  sutures 
to  the  atrophied  deltoid  and  underlying  capsule  of  the  joint. 
The  skin  wound  is  then  closed  and  the  limb  is  fixed  in  complete 
abduction  by  means  of  a  plaster  bandage.     This  attitude  should 


DISEASES   OF   THE   NEBFOUS   SYSTEM.  647 

be  retained  for  about  two  months.  Afterward  massage  and 
exercises  should  be  employed.  The  humerus  is  usually  held 
securely,  a  certain  power  of  abduction  is  restored,  and  the  func- 
tional ability  often  greatly  increased  (Figs.  428  and  429). 

If  the  capsule  is  greatly  relaxed  the  redundancy  may  be  re- 
moved before  transplanting  the  trapezius.  The  upper  portion 
of  the  pectoralis  major  muscle  has  been  used  for  the  same 
purpose. 

Paralysis  of  the  muscles  of  the  arm  and  hand  is  compara- 
tively unusual.  The  operation  of  tendon  shortening  combined 
with  transplantation  of  the  tendons  of  one  or  more  active 
muscles  may  be  of  service  in  the  treatment  of  wrist-drop,  and 
opportunities  may  suggest  themselves  in  other  situations  when- 
ever it  is  possible  to  utilize  the  muscular  power  to  better  ad- 
vantage. 

Transplantation  of  the  Saetoeius  Muscle. — In  cases  in 
which  the  quadriceps  extensor  miiscle  is  paralyzed  its  function 
may  be  in  part  restored  by  transplantation  of  the  Sartorius, 
as  suggested  by  Goldthwait.  A  slightly  curved  incision  is  made 
from  the  patella  inward  and  upward  to  the  middle  third  of  the 
thigh.  The  Sartorius  is  exposed,  divided  near  its  insertion  and 
thoroughly  separated  from  the  surrounding  parts.  Its  ex- 
tremity is  then  inserted  into  an  opening  made  in  the  tendinous 
expansion  of  the  quadriceps  muscle,  to  which  and  to  the  patella 
it  is  firmly  attached.  The  extended  position  should  be  retained 
for  several  months.  In  favorable  cases  a  useful  degree  of  power 
of  extension  is  supplied. 

The  tensor  vaginae  femoris  muscle  has  been  utilized  for  the 
same  purpose  by  IS^aegeli  in  11  cases  with  satisfactory 'results. 

Akthkodesis. — Arthrodesis  is  of  greatest  service  at  the  ankle- 
joint,  where  it  may  serve  to  fix  the  foot  at  a  right  angle  with  the 
leg.  (See:  Talipes.)  In  exceptional  cases  arthrodesis  or  ex- 
cision at  the  knee  may  be  advisable  in  the  older  patients,  but  in 
young  subjects  the  strain  upon  the  long,  weak  lever  formed  by 
the  two  bones  will  almost  always  induce  deformity.  Arthro- 
desis at  the  hip  may  be  of  service  in  cases  of  comj)lete  paralysis 
of  the  pelvic  muscles.  The  operation  is  performed  as  for  ar- 
throtomy  in  the  treatment  of  congenital  displacement  of  the  hip 
(see  page  565),  except  that  the  cartilage  is  thoroughly  re- 
moved from  the  head  of  the  femur  and  from  the  acetabulum. 
A  short  spica  plaster  support  should  be  worn  until  union  is  firm. 

Arthrodesis  at  the  shoulder  may  be  of  service  when  the  sup- 


648  OBTHOFEBIC  SUSGESY. 

porting  muscles  are  paralyzed.  The  method  of  opening  the 
joint  is  described  on  page  507. 

Arthrodesis  at  the  elbow  and  wrist  may  assume  an  improved 
attitude.  Whenever  possible  the  operation  should  be  reinforced 
by  tendon  or  muscle  transplantation.  Anchylosis  or  even  satis- 
factory fixation  can  not  be  attained  by  this  means  until  the  bones 
are  sufficiently  developed.  The  operation  should  not  be  per- 
formed therefore  until  the  child  is  at  least  eight  years  of  age. 

Osteotomy.- — In  some  instances,  particularly  in  the  extreme 
deformities  in  the  adult,  osteotomy  of  the  femur  at  the  hip  or 
knee  may  be  necessary  in  order  to  overcome  resistant  distortion. 

J^EEVE  Geaftixg. — A  number  of  operations  have  been  per- 
formed recently  with  the  aim  of  restoring  muscular  power  in 
paralyzed  muscles  by  uniting  the  inactive  nerve  with  one  which 
is  still  in  communication  with  the  nerve  centres.  Some  en- 
couraging results  have  been  reported,  but  the  operation  is  still 
in  the  experimental  stage.  It  must  be  assumed  on  the  one  hand 
that  the  inactive  and  degenerated  nerve  is  capable  of  regenera- 
tion and  on  the  other  that  the  one  to  which  it  is  attached  is 
capable  of  taking  on  a  double  function. 

Review  of  Treatment. — This  consists  in  support  and  electrical 
stimulation  of  the  muscles  during  the  period  of  recovery,  to- 
gether with  a  suitable  brace  to  hold  the  limb  in  the  best  possible 
position  for  usefulness  when  the  final  extent  of  the  paralysis  has 
become  evident.  With  the  support  any  treatment  that  will  im- 
jDrove  the  nutrition  of  the  part  is  of  service ;  massage  and 
muscle-beating  are  of  special  value.  The  limb  in  which  the 
circulation  is  deficient  should  be  protected  from  the  cold  by 
proper  covering,  and  its  nutrition  may  be  improved  by  the 
direct  application  of  heat,  the  hot-air  or  hot-water  bath  both  be- 
ing useful.  Above  all  else,  functional  use,  which  is  made  pos- 
sible by  apparatus,  is  of  the  first  importance  in  preserving  and 
stimulating  whatever  muscular  power  remains;  and  special 
gymnastic  exercises  to  this  end  may  be  employed  if  practicable. 
The  prevention  of  deformity  during  the  growing  period  is  of 
great  importance.  Every  morning  and  night  the  joints  of  the 
paralyzed  part  should  be  passively  moved  to  the  normal  limits 
in  all  directions  in  order  to  prevent  the  gradual  limitation  of  the 
range  of  motion  which  is  the  first  indication  of  the  defori^ity. 
Lateral  deviation  of  the  limb  or  foot  may  be  prevented  by 
IDassive  manipulation  and  by  careful  adjustment  or  modifica- 
tion of  the  sujDport.     Braces  should  be  strong  and  as  simple  as 


DISEASES   OF   THE   NEEVOUS   SYSTEM.  649 

may  be  in  construction.  Elastic  bands  and  springs,  applied 
with  the  design  of  replacing  paralyzed  muscles,  are  of  little 
practical  use,  since  they  are  ineffective  in  action,  difficult  to 
adjust,  and  easily  disarranged.  The  parent,  when  treatment 
is  begun,  must  be  impressed  with  the  fact  that  a  brace  must  be 
strong  enough  to  serve  its  purpose  even  though  its  weight  be 
objectionable;  that  its  period  of  usefulness  is  limited,  and  that 
it  must  be  replaced  when  it  is  outgrown ;  that  the  breaking  of  a 
brace  from  time  to  time  is  unavoidable,  and  that  such  accidents, 
in  so  far  as  they  are  evidences  of  the  functional  activity  of  the 
patient,  are  favorable  indications. 

Careful  supervision  of  the  patient,  even  though  the  weakness 
is  not  great,  will  be  necessary  during  the  period  of  growth.  The 
contrast  between  the  development  and  symmetry,  the  muscular 
power  and  practical  utility  of  a  limb  that  has  received  this  care 
and  sujDervision,  and  one  that  has  been  neglected,  is  sufficiently 
striking  to  impress  anyone  with  the  necessity  for  this  tedious 
and  apparently  never-ending  treatment. 

Thus,  in  this  as  in  other  chronic  diseases  and  disabilities  the 
character  and  the  duration  of  the  treatment,  its  object,  and  the 
final  results  that  one  may  expect  to  attain  by  it,  should  be  ex- 
plained to  the  parents  when  the  care  of  the  patient  is  under- 
taken. 


CHAPTER   XYIII. 

DISEASES  OF  THE  NEEVOUS  SYSTEM   (Continued). 

CEREBRAL  PARALYSIS  OF  CHILDHOOD— SPASTIC 
PARALYSIS. 

Cerebral  paralysis  or  palsy  is  in  orthopedic  practice  second 
only  in  frequency  and  importance  to  anterior  poliomyelitis.  It 
is,  however,  entirely  different  in  its  distribution  and  in  its 
effects.  It  is  a  form  of  disability  that  is  characterized  by  motor 
weakness,  by  stiffness  and  loss  of  control,  rather  than  by  par- 
alysis. It  affects  entire  members  and  it  results  in  atrophy,  con- 
tractions, and  deformity. 

It  may  involve  half  the  body,  hemiplegia. 

It  may  be  limited  to  the  lower  extremities,  paraplegia. 

It  may  involve  both  the  upper  and  lower  extremities,  diplegia. 

In  rare  instances  but  one  extremity  is  affected,  monoplegia. 

Distribution.^ — In  451  cases  of  cerebral  paralysis  analyzed  by 
Peterson,^  332  were  of  the  hemiplegic  type,  73  were  of  the 
diplegic  type,  and  46  were  of  the  paraplegic  type.  In  121  cases 
observed  at  the  Hospital  for  Ruptured  and  Crippled,  63  were 
paraplegic  or  diplegic  and  58  were  hemiplegic. 

Of  132  cases  of  hemiplegia  analyzed  by  Thomas  but  36  were 
of  congenital  origin,  a  large  proportion  of  the  remainder  fol- 
lowed acute  infectious  disease,  the  paralysis  resulting  from 
hemorrhage,  thrombosis,  embolism,  or  encephalitis.^ 

Etiology  and  Pathology. — Cerebral  paralysis  may  be  divided 
into  two  classes' — the  congenital  and  the  acquired.  The  diplegic 
and  paraplegic  forms  are  usually  congenital,  the  hemiplegic 
form  is  more  often  acquired. 

Congenital  Paralysis. — Paralysis  of  intrauterine  origin  may 
be  the  result  of  maldevelopment  or  injury  or  a  secondary  effect 
of  intercurrent  disease  of  the  mother.  Paralysis  caused  by  in- 
jury at  birth  is  usually  the  result  of  rupture  of  bloodvessels  of 
the  meninges  due  to  prolonged  labor  or  to  the  pressure  of  instru- 
ments. 

^  American  Text-book  of  Diseases  of  Children. 
==  Bull.  J.  Hop.  Hosp.,  June,  1909. 

650 


DISEASES   OF   THE   NEBVOUS   SYSTEM.  651 

Acquired  Paralysis. — Acquired  paralysis  may  be  due  to  hemor- 
rhage, embolism,  thrombosis,  or  to  disease.  Saehs^  presents  the 
following  classification  of  causes  and  effects : 

PaEALYSIS  of  liS'TKAUTEKINE   OrIGIN. 

Large  cerebral  defects — true  porencephaly. 

Hemorrhages  of  intrauterine  origin — softening. 

Agenesis  corticalis. 

Fig.  430. 


Congenital  cerebral  diplegia   (idiocy). 

Paealysis  Acqijieed  aftee  Bieth. 

1.  Meningeal  hemorrhage — very  seldom  intracerebral.  Em- 
bolism :  thrombosis  in  marantic  conditions,  and  occasionally 
from  syphilitic  endoarteritis.  Results  of  these  vascular  lesions : 
cysts;  softening;  atrophy;  sclerosis,  diffuse  and  lobar. 

2.  Chronic  meningitis. 

Paealysis  Occueeing  duei:n'g  Laboe. 

Meningeal  hemorrhage — very  seldom  intracerebral.     Pesult- 

^  Sachs,  jSTervous  Diseases  of  Children. 


652 


OBTHOPEDIC  SUEGEBY. 


ing  conditions  :  meningoencephalitis  chronica  ;  sclerosis ;  cysts ; 
atrophies ;  porencephalies. 

3.  Hydrocephalus. 

4.  Primary  encephalitis  (Strlimpell). 

General  Symptoms Motor. — The  effect  of  the  lesion  of  the 

hrain  and  of  the  secondary  changes  in  the  anterior  pyramidal 

Fig.  431. 


Spastic  paraplegia. 


tracts  of  the  cord  is  to  impair  the  voluntary  control  of  the  limbs 
supplied  from  the  affected  area,  and  at  the  same  time  the  in- 
hibition of  the  higher  centres  is  impaired  or  lost.  Thus,  to- 
gether with  the  loss  of  power,  there  is  a  corresponding  exaggera- 
tion of  the  reflexes  causing  a  spastic  rigidity  of  the  limbs  vary- 
ing with  the  degree  of  voluntary  control.  This  induces  distor- 
tion, Avhieh  finally  becomes  fixed  by  the  adaptive  changes  in  the 


DISEASES   OF   THE  NERVOUS   SYSTEM.  653 

tissues.  As  the  centres  for  the  nutrition  of  the  paralyzed  parts 
are  not  involved,  the  muscles  do  not  waste  and  the  circulation 
is  but  little  affected.  Thus  the  atrophy  as  compared  with  par- 
alysis of  spinal  origin  (anterior  poliomyelitis)  is  comparatively 
slight,  and  this,  together  with  the  retardation  of  growth,  is  due 
rather  to  the  general  effects  of  the  disease  and  to  the  loss  of 
function  than  to  the  direct  influence  of  the  nervous  lesion. 

Mental.— In  this  form  of  paralysis  the  lesion  is  of  the  brain, 
and  the  direct  injury  of  its  structure  and  the  interference  with 
its  development  is  likely  to  cause  mental  impairment.  This 
mental  impairment  is  usually  more  marked  in  the  paraplegic  or 
diplegic  than  in  the  hemiplegic  form,  because  in  the  latter  but 
half  the  brain  is  involved,  and  because  the  injury  or  disease 
occurs  at  a  later  period  of  its  development.  So,  also,  the  mental 
development  is  usually  less  interfered  with  in  the  paraplegic 
than  in  the  diplegic  type.  For,  although  both  hemispheres  were 
involved,  yet  the  recovery  of  power  in  the  arms  shows  that  the 
injury  was  less  extensive  than  when  the  weakness  persists  in  one 
or  both  of  the  upper  extremities. 

It  is  estimated  that  in  50  per  cent,  of  the  hemiplegic  cases  the 
patients  are  feeble-minded,  although  comparatively  few  (13  per 
cent.)  are  idiotic.  In  the  paraplegic  and  diplegic  forms  of  par- 
alysis about  YO  per  cent,  of  the  patients  are  feeble-minded,  and 
from  40  to  50  per  cent,  are  idiotic.     (Sachs.) 

Epilepsy  is  an  accompaniment  of  about  45  per  cent,  of  all 
forms  of  cerebral  paralysis,  and  in  20  per  cent,  of  the  cases 
athetoid  or  associated  movements  in  the  paralyzed  parts  persist. 
(Peterson.) 

Congenital  Weakness  and  Paralysis. — The  congenital  form  of 
cerebral  paralysis  is  often  seen  in  orthopedic  clinics,  because  the 
effect  of  the  lesion  of  the  brain  in  retarding  physical  develop- 
ment first  attracts  the  attention  of  the  mother.  Thus,  infants 
are  brought  for  examination  because  they  are  unable  to  sit  or 
stand  at  the  usual  time.  In  certain  instances  the  cause  of  the 
physical  weakness  is  simple  idiocy.  In  such  cases  the  vacant 
expression,  the  inability  of  the  child  to  recognize  even  its 
mother,  the  extreme  weakness,  and  the  absence  of  the  spastic 
rigidity  of  the  limbs  will  make  the  diagnosis  clear. 

In  another  class  of  cases  the  weakness  appears  to  be  caused 
simply  by  retarded  cerebral  development.  The  patient  is 
apathetic  and  weak,  but  there  is  no  evidence  of  paralysis  and  the 
comparative  intelligence  of  the  patient  distinguishes  this  type 
from  the  idiotic  class. 


654  ORTHOPEDIC  SURGEBY. 

In  the  characteristic  form  of  cerebral  paralysis  as  seen  in 
early  life  the  child  may  be  idiotic,  or  simply  apathetic,  or  fairly 
normal  in  intelligence,  but  it  is  always  weak,  and  in  the  sitting 
posture  the  spine  is  usually  bent  backward  into  a  long,  more  or 
less  rigid  curve.  It  makes  no  effort  to  stand,  and  when  placed 
in  the  erect  j)osture  it  will  be  noticed  that  the  thighs  are  usually 
pressed  closely  against  one  another  and  that  the  feet  are  ex- 
tended. The  limbs  are  "  stiff."  There  is  a  peculiar  resistance 
to  flexion  at  the  extended  joints,  which  slowly  gives  way  under 
steady  pressure.  This  is  the  characteristic  spastic  rigidity 
(Fig."  430). 

Deformities, — These  children  usually  begin  to  stand  and  to 
walk  at  about  the  third  year  or  later  with  an  awkward,  shuffling 
gait;  the  limbs  are  usually  flexed,  adducted,  and  rotated  in- 
ward ;  the  knees  touch  one  another  or  the  legs  may  be  crossed, 
while  the  feet  turn  inward  in  a  persistent  attitude  of  slight 
ec[uinovarus.  The  equilibrium  is  very  easily  disturbed,  partly 
because  of  the  deformities  and  partly  because  of  direct  lesion  of 
the  brain.  In  the  majoritv'  of  the  congenital  cases  the  paralysis 
is  paraplegic  in  its  distribution;  perhaps  15  per  cent,  are  of  the 
hemiplegic  variety,  and  in  a  somewhat  larger  number  the  par- 
alysis is  diplegic  in  distribution  (Fig.  430). 

The  typical  deformity  of  the  foot  is  equinovarus,  but  in 
older  subjects  who  have  walked  about  in  the  attitude  of  flexion 
at  the  hips  and  knees  there  may  be  an  accommodative  distortion 
of  the  foot  toward  valgus,  or  even  to  an  extreme  degree  of  cal- 
caneovalgTis. 

Mentality. — As  has  been  stated,  in  a  certain  number  of  cases 
the  intelligence  is  not  impaired,  but  more  often  the  patients  are 
distinctly  feeble-minded.  They  are  very  nervous,  easily  star- 
tled, emotional,  and  are  often  unable  to  speak  distinctly,  yet  it 
is  interesting  to  note  that  this  peculiar  emotional  excitability 
often  passes  for  brightness  of  intellect  and  quickness  of  percep- 
tion. In  fact,  parents  often  remain  unconvinced  that  the  child 
is  lacking  in  mental  power  until  it  reaches  an  age  when  com- 
parison with  other  children  makes  this  conclusion  inevitable. 

Acquired  Paralysis. — As  in  adult  life,  the  common  form  of 
acquired  cerebral  paralysis  in  childhood  is  hemiplegia.  About 
two-tliirds  of  all  the  cases  occur  in  the  first  three  years  of  life ; 
and  in  about  20  per  cent,  of  these  the  affection  of  the  brain  is  a 
complication  of  infectious  disease.  The  onset  is  usually  sudden, 
and  is  accompanied  in  the  majority  of  cases  by  fever,  convul- 


DISEASES   OF   THE  NERVOUS   SYSTEM. 


655 


Fig.  432. 


sions,  and  loss  of  consciousness.  When  the  child  regains  con- 
sciousness the  paralysis  of  the  arm  and  leg  is  at  once  evident, 
and  in  about  20  per  cent,  of  the  cases  the  face  is  paralyzed  also. 

Deformities, — At  first  the  paralysis  is  a  simple  powerlessness, 
but  soon  the  exaggeration  of  the  reflexes  is  evident.  As  has 
been  stated,  there  is  a  loss  of  voluntary  pov^er  and  an  increase  of 
the  reflexes  or  ^'  stiffness  "  of  the  par- 
alyzed members.  They  are  no  longer 
competent  to  assume  the  more  difii- 
cult  attitudes  and  functions,  and 
these  are  replaced  by  those  that  are 
simpler;  thus  flexion  becomes  ha- 
bitual. 

In  typical  hemiplegia  the  foot  is 
plantar  flexed  and  adducted.  The 
leg  is  flexed  on  the  thigh  and  the 
thigh  on  the  trunk,  and  w^ith  the 
flexion  adduction  is  usually  com- 
bined. The  arm  is  held  against  the 
thorax,  the  forearm  is  flexed  upon 
the  arm  in  an  attitude  midway  be- 
tween pronation  and  supination.  The 
hand  is  flexed  upon  the  arm  and  in- 
clined toward  the  ulnar  side  and  the 
fingers  are  clasped  over  the  adducted 
thumb  (Fig.  432). 

Disability. — The  loss  of  power  is 
not  absolute;  in  most  instances  the 
patient  is  able  to  walk  with  an  ex- 
aggerated limp,  dragging  the  stiff- 
ened and  distorted  limb,  which 
serves  as  a  prop .  rather  than  as  an 
active  support.  So,  also,  the  control 
of  the  upper  extremities  is  in  part 
retained;  the  patient  is  able  to  ab- 
duct the  arm,  to  partly  extend  the 
forearm,    sometimes    to    extend    the 

fingers  and  to  abduct  the  thumb,  but  the  power  to  dorsiflex  the 
hand  and  at  the  same  time  to  extend  the  fingers  is  not  usually 
retained  in  a  case  of  this  character. 

Loss  of  Growth. — The  growth  of  the  patient  as  a  whole  is 
usually  retarded  to  a  certain  extent  by  the  lesion  of  the  brain. 


Acquired    cerebral    hemiplegia. 


656  OBTHOPEDIC  SURGEEY. 

There  is  in  addition  a  certain  degree  of  inequality  in  the  growth 
of  the  two  halves  of  the  body.  This  inequality  is  more  marked 
in  the  upper  than  in  the  lower  extremity.  Shortening  to  the 
extent  of  an  inch  in  the  lower  extremity  is  not  usually  exceeded, 
but  the  growth  of  the  arm  and  hand  may  be  very  markedly 
checked.  This  disproportionate  loss  of  growth  in  the  upper 
over  the  lower  extremity,  although  it  may  be  explained  in  part 
by  the  situation  of  the  lesion. of  the  brain,  depends  more  directly 
upon  the  interference  with  function.  The  lower  extremity  is 
rarely  disabled  to  an  extent  that  prevents  its  use  in  locomotion, 
consequently  its  nutrition  is  preserved;  whereas,  the  same  de- 
gree of  paralysis  of  the  arm  utterly  unfits  it  for  its  more  difficult 
functions  and  it  becomes  a  useless  appendage.  With  the  disuse 
of  function  there  is  a  corresponding  diminution  of  nutrition 
and  a  consequent  atrophy  and  loss  of  growth. 

Extreme  deformity  and  disability,  as  in  the  type  described, 
are  rather  unusual.  In  many  instances  there  is  almost  com- 
plete recovery  from  the  paralysis,  only  an  awkwardness  and 
slowness  of  movement,  combined  with  an  increase  of  reflexes  and 
a  slight  hemiatrophy  of  the  body  exists.  In  some  cases  a  slight 
degree  of  equinus  is  the  only  deformity;  in  others  weakness  of 
the  arm  may  persist,  although  complete  control  of  the  lower 
extremity  has  been  regained. 

The  final  effect  of  the  paralysis  is  almost  always  more  marked 
in  the  upper  than  in  the  lower  extremity;  thus,  when  contrac- 
tions and  deformiities  of  the  lower  extremity  are  present  the 
arm  and  hand  are  ofcen  practically  disabled. 

Treatment. — 1.  Hemiplegia.^ — -The  treatment  from  the  ortho- 
pedic standpoint  consists  in  stimulating  the  nutrition  of  the 
paralyzed  parts,  in  preventing  deformity,  and  in  improving  the 
functional  ability.  The  results  of  treatment  are,  of  course,  very 
greatly  influenced  by  the  mental  condition  of  the  patient.  If 
the  mental  power  is  not  impaired  one  may  count  upon  the  efforts 
of  the  patient  for  aid ;  whereas,  if  the  patient  is  idiotic  there  is 
but  little  encouragement  for  active  treatment.  If  the  patient 
is  seen  before  the  secondary  contractions  have  appeared,  de- 
formity may  be  prevented  in  great  degree  by  regular  massag*^ 
and  by  passive  movements  in  the  directions  opposed  to  the 
habitual  positions.  If  the  spastic  contraction  is  slight  a  light 
jointed  leg  brace  attached  to  a  pelvic  band  may  be  used.  By 
this  means  the  movements  are  controlled  and  the  excessive  ex- 
penditure of  nervous  energy  necessary  to  guide  the  limb  may  be 


DISEASES   OF   THE  NEBVOUS   SYSTEM.  657 

lessened.  If  the  support  is  supplemented  by  massage  and  regu- 
lar exercises  the  control  of  the  limb  may  be  greatly  improved. 

In  many  instances  the  patients  are  not  seen  until  late  child- 
hood, when  the  deformities  have  become  fixed.  The  foot  is 
usually  turned  inward  and  downward  (equinovarus)  ;  there  is 
flexion  at  the  knee  and  often  flexion  and  adduction  at  the  hip, 
the  resistance  of  the  contractions  being  dependent  upon  the 
duration  of  the  deformity.  In  such  cases  the  distortions  must 
be  corrected  by  force  and  by  division  of  more  resistant  tissues, 
including  often  the  tendo  Achillis,  the  plantar  fascia,  and  in 
many  instances  the  hamstrings  and  the  adductors  of  the  hip. 
The  limb  is  then  fixed  in  a  plaster-of-Paris  bandage  for  a  suffi- 
cient time  to  overcome  the  more  direct  tendency  to  deformity. 
In  correcting  hemiplegic  or  paraplegic  deformity  one  should  be 
particular  to  overcome  resistant  contraction  at  the  knee  before 
dividing  the  tendo  Achillis,  for  if  the  patient  is  permitted  to 
walk  afterward  with  a  flexed  knee  calcaneus  deformity  may  be 
induced.  Division  of  the  hamstring  tendons  through  an  open 
incision  is  therefore  indicative  in  all  resistant  cases  of  this  class. 
As  additional  precaution  the  foot  at  the  time  of  an  operation 
should  be  fixed  at  a  right  angle  with  the  limb ;  not  overcorrected 
as  is  usual.  When  the  bandage  is  removed  a  brace  is  of  service 
in  guiding  the  limb,  and  regular  massage  and  forcible  passive 
movements  together  with  proper  exercises  should  be  employed 
whenever  practicable.  In  this  class  of  cases  the  deformities 
may  be  overcome  in  most  instances,  but  there  is  a  tendency 
toward  flexion  at  the  knee,  and  stiffness  and  awkwardness  in 
movement  usually  persist. 

In  many  of  the  milder  hemiplegic  cases  the  only  deformity 
is  of  the  foot.  This  should  be  treated  by  division  of  the  tendo 
Achillis  and  by  support  for  a  time  until  the  deformity  habit 
has  disappeared. 

If  the  arm  is  but  slightly  affected  persistent  exercise  will 
greatly  improve  its  ability.  In  the  more  extreme  cases,  in 
which  the  fingers  are  clasped  over  one  another,  treatment  is  of 
little  avail.  In  another  class,  in  which  the  patient  has  the 
power  of  extending  the  fingers  only  when  the  wrist  is  flexed,  the 
power  of  dorsiflexion  may  be  restored  or  improved  by  trans- 
planting the  flexors  of  the  carpus  on  the  radial  and  ulnar  border 
to  the  extensors,  which  have  been  overlapped  and  shortened  to 
the  proper  extent.  These  tendons  may  be  exposed  by  lateral 
incisions,  and  may  be  attached  to  the  dorsal  tendons  by  passing 
42 


658 


ORTHOPEDIC  SUEGEE7. 


them  about  the  border  of  the  radius  and  of  the  ulna,  or  the 
tendons  may  be  elongated  by  silk,  which  may  be  inserted  directly 
to  the  median  surface  of  the  carpus  or  metacarpus.  In  such 
instances  one  hopes  that  fibrous  tissue  will  be  deposited  about 
the  artificial  tendon  and  finally  replace  it.  In  other  instances 
the  two  tendons  have  been  pushed  through  an  opening  in  the 
interosseous  membrane  to  the  dorsal  surface  of  the  wrist,  and 

Fig.  433. 


Cerebral  paraplegia,  second  stage  in  treatment,  the  long  replaced  by  the 
short  spica.  This  patient,  at  the  age  of  eight  years,  was  unable  to  stand  with- 
out assistance.  The  spastic  contractions  and  deformities  were  overcome  by 
tenotomies  and  by  force,  and  a  double  long  spica  bandage  was  applied.  This  was 
worn  for  eight  months.  It  was  then  replaced  by  the  bandage  shown  in  the 
illustration.  Six  months  later  this  was  removed.  There  is  at  present  no  de- 
formity, and  the  child  walks  fairly  well. 


there  united  with  the  tendons  of  the  extensors  of  the  fingers. 
The  results  of  these  operations  as  far  as  improving  the  attitude 
is  concerned  are  usually  good.     The  transplantation  of  other 


DISEASES   OF   TEE  NEEVOUS   SYSTEM.  659 

tendons  may  be  of  service,  but  the  operation  is  limited  in  useful- 
ness for  the  reasons  stated.  Athetoid  movements  of  tbe  band 
and  arm  may  be  relieved  somewhat  by  prolonged  fixation  in  a 
plaster  bandage,  or  by  arthrodesis  at  the  w^rist-joint. 

2.  Paraplegia. — The  treatment  of  spastic  paraplegia  is  more 
difficult  than  that  of  hemiplegia,  because  the  disability  is  very 
much  greater  and  because  the  mental  impairment  is  usually 
more  marked. 

In  general,  the  treatment  in  infancy  is  by  massage  and  by 
manipulation.  When  the  child  shoves  a  desire  to  walk  an  at- 
tempt should  be  made  to  relieve  the  spastic  contractions.  In 
certain  instances  complete  correction  of  all  deformities,  followed 
by  prolonged  fixation  of  each  joint  in  the  overcorrected  attitude, 
may  be  of  service  (Fig.  433).  This  may  be  combined  with  mul- 
tiple tenotomies  if  the  contractions  are  more  resistant.  The 
advantage  of  tenotomy,  aside  from  the  simple  correction  of  de- 
formity, is  that  by  elongation  of  the  tendon  the  response  to  the 
exaggerated  motor  impulses  is  lessened  and  an  opportunity  for 
more  effective  control  is  afforded.  The  beneficial  effect  of  com- 
plete division  of  contracted  parts  in  checking  spasmodic  contrac- 
tions is  very  marked  in  older  patients. 

Foster  has  suggested  an  operation  for  the  purpose  of  lessen- 
ing the  constant  stimulation  of  the  spinal  reflexes  by  laminec- 
tomy and  division  of  the  posterior  nerve  roots  of  the  lumbar 
and  upper  sacral  nerves  in  cases  of  the  paraplegic  type  and  of 
the  cervicodorsal  roots  if  the  upper  extremities  are  involved. 
Six  cases  have  been  reported  by  Tietz^  with  one  death. 

A.  S.  Taylor  has  modified  the  operation  and  in  the  place  of 
complete  laminectomy  removes  a  lateral  section  between  the 
spinous  and  the  articular  processes  with  the  Doyen  saw.  The 
dura  is  then  opened  and  the  jDOsterior  roots  of  the  lumbar  and 
first  sacral  nerves  are  divided  on  the  dorsal  side  of  the  ganglion. 
The  immediate  result  in  two  cases  was  very  good.^ 

Tendon  Tkansplantation.^ — Transplantation  of  tendons 
from  the  flexor  to  the  extensor  aspect  of  the  limb  to  overcome 
persistent  flexion  of  the  knee  may  be  of  service  in  certain  cases. 
According  to  the  method  of  Lange,  the  tendons  are  exposed  by 
incisions  on  the  lower  lateral  aspects  of  the  knee.  They  are 
divided  and  are  carried  forward  beneath  the  skin  and  are  attached 
to  the  insertion  of  the  quadriceps  extensor  tendon,  which  is  exposed 
by  a  median  incision.   The  actual  insertion  is  usually  made  by  a 

^  Mit.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  B.  xx.,  3.  H. 
^N.  Y.  Medical  Record,  Dec.  18,  1909. 


660  OBTHOPEDIC  SUEGEBY. 

strong  cord  of  silk  prolonged  from  the  extremity  of  each  tendon. 
This  is  necessary  to  give  it  sufficient  length.  The  good  effect 
of  the  operation  is  to  be  ascribed  in  far  greater  degree  to  the 
removal  of  the  deforming  force  than  to  the  extending  action  of 
the  flexor  muscles  acting  at  such  mechanical  disadvantage.  In 
several  cases  the  transplantation  of  all  the  flexors  has  been  fol- 
lowed by  hyperextension  deformity  at  the  knee.  Except  in  the 
very  mild  cases  of  paraplegia,  and  as  a  temporary  support  to 
retain  the  limbs  in  the  imj)roved  position  after  operative  treat- 
ment, braces  are  of  little  value.  The  trunk  is  not,  as  a  rule, 
deformed  except  in  the  diplegic  cases  in  which  the  mental  im- 
pairment is  great.  Manipulation,  massage,  and  educational 
gymnastics  are  of  service  in  correcting  and  preventing  this  dis- 
tortion. 

Prognosis. — It  is  stated  by  Peterson^  that  the  patients  in 
whom  the  paralysis  is  paraplegic  or  diplegic  in  distribution 
usually  die  before  the  twentieth  year,  and  that  but  few  of  those 
in  whom  it  is  hemiplegic  reach  the  age  of  forty.  This  prognosis 
applies,  it  may  be  assumed,  rather  to  the  extreme  cases  accom- 
panied by  mental  impairment  than  to  the  milder  forms.  In 
almost  all  cases  the  patient,  even  if  idiotic,  is  finally  able  to 
stand  and  to  walk.  As  a  rule,  there  is  for  a  time  a  gradual  im- 
provement in  motor  power  and  in  mental  control  as  well.  It  is 
evident  that  in  a  class  in  which  mental  enfeeblemeut  is  so  com- 
mon and  in  which  epilepsy  is  present  in  so  large  a  proportion  of 
cases,  moral  and  mental  training  is  of  great  importance. 

Orthopedic  treatment,  although  it  has  no  direct  action  upon 
the  lesion  in  the  brain,  certainly  has  an  indirect  effect  upon  the 
mental  as  well  as  upon  the  physical  condition  of  the  patient. 

When  deformity  has  been  corrected  and  when  contractions 
have  been  overcome,  functional  use  requires  less  mental  effort ; 
and  motor  control  may  be  still  further  improved  by  drilling  the 
patient  constantly  in  simple  movements.  Such  exercises  im- 
prove the  motor  communications  and  the  ability  of  the  paralyzed 
l^art  as  well. 

SPASTIC   SPINAL  PARALYSIS. 

Occasionally  cases  of  spastic  paraplegia  are  seen  in  which 
there  is  no  cerebral  impairment.  In  such  cases  the  lesion  ap- 
pears to  be  confined  to  the  spinal  cord  and  to  be  a  degeneration 
of  the  distal  portions  of  the  pyramidal  tracts  due  to  imperfect 

^  Transactions  American  Orthopedic  Association,  1900,  vol.  xiii. 


DISEASES   OF   THE  NEBVOUS   SYSTEM.  661 

development.-^     The  treatmeii't  is  similar  to  the  ordinary  form  of 
spastic  paraplegia,  bnt  the  prognosis  is  far  more  encouraging. 

PROGRESSIVE  MUSCULAR  ATROPHY. 

Progressive  muscular  atrophy,  as  the  term  implies,  is  a  pro- 
gressive wasting  of  the  muscles,  with  corresponding  loss  of 
power,  terminating  finally  in  paralysis  and  deformity.  Its 
cause  is  apparently  developmental  defect. 

Under  this  title  are  included  two  varieties  of  disease : 

1.  The  myelopathic  form,  in  which  the  primary  disease  is 
apjDarently  of  the  spinal  cord. 

2.  The  myopathic  form,  in  which  the  disease  appears  to  be 
primarily  of  the  nerve  terminals  and  the  muscular  fibres. 

The  second  variety  is  usually  designated  as  muscular  dys- 
trophy to  distinguish  it  from  the  spinal  form. 

Myelopathic  Paralysis  or  Atrophy. — The  myelopathic  form 
of  muscular  atrophy,  the  Aran-Duchenne  type,  usually  begins 
in  the  small  muscles  of  the  hands  and  spreads  from  the  periph- 
ery to  the  trunk.  Fibrillary  twitching  of  the  affected  and  un- 
affected muscles  is  fairly  constant,  and  the  reaction  of  degenera- 
tion may  be  present.  The  disease  is  practically  limited  to 
adults,  and  from  the  orthopedic  standpoint  it  is  of  little  interest. 
In  another  form,  the  Charcot-Marie-Tooth  type,  usually  classed 
with  the  muscular  atrophies,  the  paralysis  may  begin  in  the 
muscles  of  the  legs,  causing  deformity  of  the  equinus  or  equino- 
varus  variety.  The  lesion  of  the  cord  is  of  the  anterior  cornua, 
and  resembles  closely  that  of  the  subacute  form  of  anterior  polio- 
myelitis. 

Myopathic  Paralysis  or  Muscular  Dystrophy. -^The  myo- 
pathic form  of  muscular  atrophy  may  be  preceded  by  apparent 
hypertrophy  (pseudohypertrophic  muscular  paralysis),  it  may 
be  primarily  atrophic,  or  the  two  forms  may  be  combined. 

It  differs  from  the  myelopathic  form  in  several  particulars. 
It  is  a  disease  of  childhood.  It  is  often  hereditary  and  its  dis- 
tribution is  different. 

The  affection  is  divided  according  to  the  distribution  into  two 
main  varieties : 

1.  The  facio-scapulo-humeral  type  (Landouzy-Dejerine),  in 
which  the  muscles  of  the  face  and  shoulder  girdle  are  primarily 
affected  (Fig.  435). 

^  Spiller,  Philadelphia  Medical  Journal,  June  21,  1902. 


662 


OBTHOPEDIC  SUBGEBY. 


%.  The  juvenile  form  of  Erb,  in  which,  the  muscles  of  the 
back  and  of  the  upper  arms  are  first  involved. 

The  etiology,  pathology,  and  clinical  course  of  the  atrophic 
do  not  differ  essentially  from  the  pseudohypertrophic  form. 


Fig.  434. 


Fig.  435. 


Progressive  muscular  dystrophy, 
showing  the  enlargement  of  the 
calves  and  the  atrophy  of  the 
shoulder   muscles. 


Progressive  muscular  dystrophy,  facio- 
scapulo-humeral  type.  Extreme  lordosis 
and  flexion  contractions  at  the  hips. 


Pseudohypertrophic  Muscular  Paralysis. — Pseudohypertro- 
phic paralysis  is  characterized  by  progressive  weakness  of  the 
muscles  of  the  trunk  and  of  the  legs,  associated  with  apparent 
hypertrophy  of  the  calves  due  in  great  part  to  a  deposit  of  fat 
in  the  wasting  muscles  (Fig.  434). 


DISEASES   OF   THE   NERVOUS   SYSTEM.  663 

The  symptoms  are  caused  by  a  degenerative  atrophy  of  the 
nerve  terminals  and  of  the  muscular  fibres  and  an  increase  of 
the  connective  tissue  and  replacement  of  the  muscular  substance 
by  fat. 

Diagnosis. — The  interest  in  this  latter  affection  from  the  ortho- 
pedic standpoint  lies  in  the  diagnosis  in  the  early  stage  of  the 
affection.  At  this  time  the  patient  is  evidently  weak ;  he  walks 
with  an  awkward,  shambling  gait,  and  climbing  stairs  is  espe- 
cially difficult.  There  is  usually  an  increased  lordosis  and  a 
peculiar  swaying  or  waddle,  a  disinclination  to  stoop,  and  an 
evident  difficulty  in  regaining  the  erect  posture,  and  there  may 
be  discomfort  or  pain  referred  to  the  lumbar  region.  If  the 
disease  is  advanced,  the  peculiar  hard,  resistant  enlargement  of 
the  calves,  combined,  it  may  be,  with  atrophy  of  the  muscular 
groups  of  the  upper  extremity,  and  weakness  of  the  muscles  of 
the  back,  makes  the  diagiiosis  evident,  but  in  young  children  the 
disease  may  be  mistaken  for  Pott's  disease,  simple  weakness,  or 
postural  deformity.  Although  there  is  a  superficial  resemblance 
to  the  general  symptoms  of  Pott's  disease,  yet  the  specific  signs 
of  disease  of  the  vertebrae,  pain,  and  muscular  spasm  are  absent. 

Weakness,  a  result  of  malnutrition  or  disease,  is  general  in 
character  and  its  cause  is  usually  apparent ;  it  is,  of  course,  not 
accompanied  by  local  hypertrophy.  Retarded  cerebral  develop- 
ment causes  general  weakness  as  far  as  inability  to  stand  is  con- 
cerned, but  the  cause  is  in  this  class  also  usually  apparent. 

Postural  deformities  in  childhood  always  have  a  cause,  and 
as  one  is  not  content  to  treat  a  deformity  without  ascertaining 
its  cause,  this  search  will  bring  to  light  the  peculiar  symptoms 
of  the  disease. 

Treatment. — In  certain  instances  the  discomfort  referred  to 
the  back,  due  in  part  to  the  lordosis,  may  be  relieved  by  a  light 
spinal  support.  Massage  and  muscle-training  will  enable  the 
patient  to  utilize  the  remaining  power  to  best  advantage. 

In  the  later  stages  of  the  disease  there  may  be  secondary  de- 
formities, most  marked  in  the  feet,  which  may  be  fixed  in  the 
equinus  or  equinovarus  attitude.  This  deformity  may  be  cor- 
rected by  tenotomy  or  otherwise,  if  the  disability  is  not  progress- 
ing rapidly. 

HEREDITARY  ATAXIA.    FRIEDREICH'S  DISEASE. 

Hereditary  ataxia  is  an  ataxic  paraplegia  caused  by  sclerosis 
of  the  posterior  and  lateral  columns  of  the  spinal  cord.     The 


664  OBTHOPEDIC  SURGERY . 

early  sjnij)toiiis  are  inco-ordination  and  weakness  of  the  legs ; 
later  similar  symptoms  appear  in  the  upper  extremities,  and 
speech  is  affected.  In  well-marked  cases  there  is  usually  distor- 
tion of  the  feet  toward  equinus  or  equinovarus,  and  occasionally 
a  posterior  or  lateral  curvature  of  the  spine.  In  one  case  re- 
cently under  treatment  at  the  Hospital  for  Ruptured  and  Crip- 
pled, the  rectification  of  the  deformity  of  the  feet  was  at  least 
of  temporary  benefit. 

NEURITIS. 

Localized  neuritis  after  contagious  disease  or  from  other 
causes  may  result  in  temporary  weakness  or  paralysis  of  the 
dorsal  flexors  of  the  foot,  cause  toe-drop,  and,  finally,  deformity. 
In  such  cases  the  foot  should  be  supported  by  a  brace  in  normal 
position.  This  not  only  prevents  deformity,  but  it  hastens  the 
cure  by  preventing  tension  upon  and  structural  lengthening  of 
the  weakened  muscles.  The  same  treatment  may  be  applied  for 
wrist-drop  from  metallic  poisoning.  The  hand  should  be  sup- 
ported by  a  suitable  brace  in  the  attitude  of  dorsiflexion  until 
the  muscles  have  recovered  their  power.  Obstetrical  paralysis 
has  been  considered  under  affections  of  the  shoulder. 

HYSTERICAL    JOINT    AFFECTIONS    AND    DEFORMITIES. 
FUNCTIONAL  AFFECTIONS  OF  THE  JOINTS. 

.  So-called  hysterical  and  functional  affections  may  be  divided 
into  two  groups : 

1.  Those  in  which  there  is  no  actual  disease  or  weakness. 

2.  Those  in  which  the  symi^toms  of  disease  or  injury,  or  of 
their  effects,  are  exaggerated  or  persist  unduly. 

The  first  class  of  cases  is  small,  the  second  is  large. 

Simulation,  whether  voluntary  or  involuntary,  of  organic  dis- 
ease can  deceive  only  those  who  are  not  familiar  with  the  char- 
acteristics of  the  disability  that  is  simulated.  Every  disease  has 
certain  well-defined  symptoms  which  can  no  more  be  imitated 
by  a  well  person  than  a  disabled  part  can  suddenly  take  on  the: 
normal  appearance  and  function. 

THE  NEUROTIC  SPINE. 

The  "  neurotic  "  spine  is  much  more  common  in  adolescence 
and  in  adult  life  than  in  childhood,  and  the  subjects,  usually 
females,  are  often  of  a  nervous  or  neurasthenic  type.     In  cer- 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


665 


tain  instances  the  symptoms  appear  to  be  induced  by  injury, 
and  in  others  by  worry  or  overwork. 

Symptoms. — The  patient  usually  complains  of  a  dull  pain  in 
the  back  of  the  neck,  or  in  the  lumbar  or  sacral  region,  of  a  con- 
stant tired  feeling,  and,  not  infrequently,  of  sharp  neuralgic 
pain  localized   about   a  certain  point  in  the  spine,  often  the 

Fig.  436. 


The  neurotic  spine.     Characteristic  attitude. 

vertebra  prominens.  The  contour  of  the  spine  may  be  normal, 
but  most  often  there  is  a  lessening  of  the  lumbar  lordosis,  a 
backward  inclination  of  the  body  and  a  forward  droop  of  the 
head,  an  attitude  that  signifies  muscular  weakness  and  strain 
upon  the  ligaments.  One  of  the  common  symptoms  of  the 
"neurotic  spine  is  extreme  local  sensitiveness,  or  hypersesthesia,  of 
the  skin  at  certain  points  along  the  spinous  processes.  Thus, 
if  one  passes  the  finger  gently  along  the  spine  the  patient  will 


666  OBTHOPEDIC  SURGEBY. 

often  shrink  or  cry  out  because  of  the  pain.  As  a  rule,  there  is 
no  limitation  of  motion  or  muscular  spasm.  The  pain  is  local, 
not  referred  to  the  terminations  of  the  nerves ;  in  fact,  the  symp- 
toms are  in  great  part  subjective  and  irregular  in  character,  as 
contrasted  with  those  of  actual  disease,  which  are  objective  and 
well-defined. 

Treatment. — The  treatment  of  the  neurotic  spine  must  be 
general  in  character,  as  indicated  by  the  condition  of  the  patient. 
Locally,  a  light  back  brace  or  a  long  corset,  reinforced  if  neces- 
sary by  light  steel  back  bars,  adds  greatly  to  the  comfort  of  the 
patient.  The  application  of  the  cautery  is  particularly  effica- 
cious in  relieving  the  local  sensitiveness.  Massage  and  light 
exercises  may  be  employed  in  the  later  treatment.  Weak  feet 
are  often  associated  with  this  condition.  In  such  instances 
appropriate  treatment  often  induces  a  marked  improvement  in 
the  general  condition. 

THE  HYSTERICAL  SPINE. 

The  hysterical  spine  is  considered  usually  as  synonymous 
with  the  neurotic  spine,  but  as  there  are  many  individuals  who 
suffer  from  sensitive  spines  who  are  not  hysterical,  it  would 
seem  proper  to  limit  the  latter  term  to  the  hysterical  class. 

Symptoms. — The  local  symptoms  do  not  differ  particularly 
from  those  of  the  neurotic  spine  except  that  in  certain  instances 
actual  deformity  may  be  present.  This  is  usually  an  exag- 
gerated lateral  distortion,  most  marked  in  the  lumbar  region. 
Like  hysterical  distortions  elsewhere,  it  may  follow  injury,  and 
it  may  be  claimed  that  this  injury  was  the  direct  cause  of  the 
deformity.  Except,  however,  as  possible  cause  of  the  appear- 
ance of  a  particular  manifestation  of  the  mental  condition,  it  is 
evident  that  no  form  of  injury  could  explain  the  symptoms  or 
the  deformity. 

' '  Hysterical  Scoliosis. ' ' — A  case  was  at  one  time  under  the 
writer's  observation  in  which  distortion  of  the  trunk  persisted 
for  more  than  a  year,  and  until  a  suit  for  damages  was  finally 
decided.  In  this  case  there  was  a  most  exaggerated  lateral  twist 
of  the  spine,  so  that  the  shoulder  approached  the  pelvis.  The 
deformity,  however,  was  not  fixed,  but  it  could  be  completely 
reduced  when  the  patient  was  in  the  recumbent  posture.  There 
was  no  paralysis,  no  persistent  spasm,  no  evidence  of  disease  or 
injury.     The  deformity  was  of  a  nature  that  could  not  be  ex- 


DISEASES   OF   THE   NERVOUS   SYSTEM.  667 

plained  by  any  conceivable  lesion,  and  other  signs  of  hysteria 
were  present.  Spontaneous  cure  then  followed  to  be  succeeded 
several  years  later  by  hysterical  "  club  feet." 

"  Hysterical  Hip."- — The  hysterical  hip  is  supposed  to  simu- 
late actual  tuberculous  disease. 

Diagnosis. — The  symptoms  of  actual  disease  of  this  joint  are 
pain,  limp,  limitation  of  motion  due  to  reflex  muscular  spasm, 
muscular  atrophy,  distortion,  and  later  the  local  signs  of  a  de- 
structive process ;  for  example,  heat,  swelling,  abscess,  displace- 
ment, shortening  of  the  limb,  and  the  like.  As  these  later  symp- 
toms could  not  be  simulated,  they  need  not  be  considered. 

In  actual  disease  symptoms  and  effects  follow  one  another 
in  regular  sequence  and  correspond  closely  to  the  pathological 
conditions  that  cause  them.  Pain  is  not  a  pronounced  symp- 
*tom;  it  is  more  likely  to  be  concealed  than  exaggerated  and  it 
is  usually  referred  to  the  knee.  Local  sensitiveness  is  not 
marked,  and  it  is  often  absent.  Distortion  of  the  limb  if  present 
before  the  destructive  changes  are  advanced,  is  caused  by  in- 
voluntary muscular  contraction,  and  whenever  this  distortion  is 
great  the  reflex  muscular  spasm,  which  involves  every  muscle 
about  the  joint,  is  also  great;  so  that  the  range  of  motion  is 
restricted.  With  the  distortion  there  is  always  a  corresponding 
atrophy  of  the  muscles  of  the  limb.  If  pain  is  present  it  is  usu- 
ally worse  at  night  than  during  the  day, 

-  The  simulation  of  hip  disease  is  characterized  by  an  exag- 
geration of  the  symptoms  and  by  absence  of  the  physical  sigiis 
of  disease.  There  is  usually  an  extreme  limp,  great  distortion, 
marked  local  sensitiveness  and  pain,  but  absence  of  muscular 
spasm,  atrophy,  or  other  signs  of  disease. 

The  age  of  the  patient,  the  history  of  the  supposed  disease, 
and  the  other  evidences  of  hysteria  that  are  usually  present  will 
confirm  the  diagnosis. 

The  same  principle  applies,  of  course,  to  the  differential  diag- 
nosis of  simulated  disease  at  other  joints.  The  knee  and  the 
hip-joint  are  those  that  are  most  often  involved. 

* '  Hysterical  Talipes, ' ' — Local  deformity  distinct  from  simu- 
lated joint  disease  is  sometimes  seen.  The  differential  diagnosis 
is  simple. 

Talipes  is  either  congenital  or  acquired.  Congenital  talipes 
and  all  the  acquired  varieties,  other  than  those  of  paralytic 
origin,  may  be  at  once  excluded  from  consideration.     Paralytic 


668  OETHOPEDIC  SUBGESY. 

talipes  in  the  great  majority  of  cases  begins  in  early  childhood, 
when  it  is  either  caused  by  anterior  poliomyelitis  or  by  cerebral 
hemiplegia  or  paraplegia.  When  these  are  excluded  the  re- 
maining causes  of  deformity  are  very  limited.  Each  variety  of 
nervous  disease  has  well-defined  symptoms.  If  actual  paralysis 
is  present  the  muscles  atrophy  and  the  electrical  reactions  are 
changed.  In  hysterical  contractions  the  muscles  are  not  atro- 
phied excejDt  to  the  degree  exjjlained  by  disuse  of  the  limb,  and 
the  electrical  reactions  are  unchanged. 

Treatment.- — The  j)rinciples  of  the  treatment  of  pronounced 
hj^steria,  of  which  simulated  joint  disease  or  deformity  are  but 
unusual  manifestations,  need  not  be  considered  at  length.  It  is 
evident,  of  course,  that  an  unequivocal  diagnosis  must  be  the 
first  and  essential  step  toward  cure.  In  this  class  of  cases  ap- 
paratus is  not  often  indicated  unless  the  deformity  has  persisted 
for  so  long  a  time  that  the  disused  muscles  have  become  inca- 
pable of  performing  their  proper  functions. 

"  Neurotic  Joints." — In  this  class,  although  there  is  no  abso- 
lute distinction  between  it  and  the  preceding  variety,  there  is 
usually  a, physical  basis  for  the  sjanptoms,  however  much  they 
may  be  exaggerated. 

The  patients  are  not  usually  hysterical;  in  fact,  hysteria  in 
the  ordinarily  accepted  sense  is  uncommon,  and  although  the 
larger  proportion  of  patients  are  women,  yet  men  and  children 
are  by  no  meiins  exempt  from  the  so-called  functional  affections. 

It  must  be  borne  in  mind,  also,  that  many  of  these  cases  are 
classed  as  neurotic  simply  because  the  cause  of  the  symptoms  is 
not  apparent.  It  may  be  inferred  that  as  diagnosis  becomes 
more  accurate  the  more  restricted  will  become  the  class  of  cases 
of  purely  imaginary  disability,  in  so  far  at  least  as  the  locomo- 
tive apparatus  is  concerned. 

Etiology.. — A  "neurotic  joint"  is  often  caused  by  injury.  A 
sprain  of  the  ankle,  for  example,  may  have  been  treated  by 
prolonged  fixation,  either  because  the  patient  had  originally 
impressed  the  physician  with  the  severity  of  the  symptoms  or 
because  of  persistent  discomfort.  When  the  dressing  is  re- 
moved there  may  be  congestion  due  to  impaired  circulation, 
weakness  and  atrophy  of  the  muscles  due  simply  to  disuse,  and 
a  certain  degree  of  infiltration  and  stiffness  caused  by  the 
original  injury.  In  cases  of  this  character  the  disability  may 
be  prolonged  because  the  patient  or  the  physician  mistakes  the 
effects  of  disuse  for  the  symptoms  of  serious  injury  or  disease. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  669 

The  treatment,  therefore,  should  be  directed  to  increasing  the 
activity  of  the  circulation  and  thus  the  nutrition  of  the  part,  by 
counter-irritation,  by  massage,  by  passive  movements,  by  volun- 
tary exercises  and  the  like,  but  cure  can  only  be  completed  by 
functional  use.  If  the  disability  is  of  long  standing  a  brace 
may  be  required  for  a  time  to  protect  the  part  from  injury, 
and  to  increase  the  patient's  confidence.  In  milder  cases  it  is 
possible  that  without  support  or  treatment,  other  than  an  assur- 
ance of  the  absence  of  serious  weakness,  cure  may  be  accom- 
plished, but  this  is  certainly  unusual. 

Symptoms.- — The  knee-joint  is  very  often  the  seat  of  so-called 
neurosis.  Injury  in  nervous  children  is  sometimes  followed  by 
a  persistent  flexion  contraction  that  may  continue  for  weeks 
after  all  local  signs  have  disappeared.  When  the  attempt  is 
made  to  straighten  the  knee  the  patient  screams  with  pain  and 
the  muscular  resistance  is  very  great.  In  such  cases  the  imme- 
diate rectification  of  deformity  under  anaesthesia  and  the  appli- 
cation of  a  plaster  bandage  to  hold  the  limb  in  the  corrected 
position  is  indicated.  It  must  be  borne  in  mind  that  the  per- 
sistent assumption  of  a  deformed  position  for  weeks  or  months 
must  induce  structural  changes  in  the  contracted  muscles  and 
weakness  in  the  opposing  groups.  Thus  some  assistance  may  be 
required  in  the  treatment  even  of  the  purely  hysterical  eleformi- 
ties  because  of  this  weakness. 

In  all  forms  of  traumatic  neurosis,  so-called,  the  possibility 
of  a  physical  basis  for  the  symptoms  should  be  considered,  the 
location  of  the  pain  or  discomfort,  and  its  connection  with  cer- 
tain movements  or  attitudes  should  be  investigated.  If  such 
discomfort  is  induced  by,  or  is  aggravated  by  a  certain  motion 
or  .attitude  it  is  reasonable  to  infer  that  this  has  a,  definite  cause. 
In  such  cases  limitation  of  the  movements  for  a  time  to  the 
painless  range  of  motion  by  some  form  of  support  may  be  in- 
dicated. 

Thus  far  injury  has  been  considered  as  the  starting  point  of 
the  symptoms,  but  in  many  cases  there  is  no  history  of  injury. 
In  this  class  the  symptoms  may  have  been  induced  by  some  form 
of  arthritis,  or  by  neuritis,  and  such  possible  causes  should  be 
investigated  and  excluded  before  the  diagnosis  of  simple  neu- 
rosis is  made.  In  neurasthenic  patients  or  those  who  are 
anaemic,  or  overworked,  the  pain  and  discomfort  is  often  local- 
ized in  the  spine,  the  "  neurotic  spine  "  which  has  already  been 
considered. 


670  OUTHOPEBIC  SUEGERY. 

Treatment. — In  the  treatment  of  all  cases  of  this  gTonp  the 
general  condition  of  the  patient  should  receive  consideration, 
and  in  connection  with  the  local  treatment  a  change  of  occupa- 
tion and  of  scene  is  often  of  advantage. 

It  is  hardly  necessary  to  insist  again  that  an  accurate  diag- 
nosis is  the  first  essential  of  successful  treatment.  If  this  is 
impossible  at  least  one  may  by  the  exclusion  of  those  injuries 
and  disabilities  and  diseases  that  are  evidently  not  present 
arrive  at  a  general  conclusion  as  to  the  character  of  the  ailment 
and  shape  his  treatment  accordingly. 


CHAPTEE   XIX. 

CO^^GENITAL  AND   ACQUIEED   TORTICOLLIS. 

Synonym.^ — Wryneck. 

Torticollis  is,  as  the  name  implies,  a  twisted  neck,  a  distor- 
tion caused  in  most  instances  by  active  contraction  or  by  short- 
ening of  one  or  more  of  the  lateral  muscles  that  control  the  head. 

Similar  distortion  may  be  due  to  disease  of  the  spine,  so- 
called  false  torticollis,  but  this  should  be  classed  as  a  symptom 
of  the  underlying  disease,  not  as  simple  torticollis,  of  which  the 
distortion  itself  is  the  important  disability  that  demands  treat- 
ment. 

Torticollis  may  be  divided  primarily  into  two  classes:  The 
congenital  and  the  acquired. 

Congenital  torticollis  is  a  painless  shortening  of  the  tissues  on 
on  side  of  the  neck  of  intrauterine  origin. 

Acquired  torticollis  is,  in  most  instances,  accompanied  in  its 
early  stages  by  local  pain  and  sensitiveness,  and  by  active  con- 
traction of  the  affected  muscles.  After  a  time  these  acute  symp- 
toms disappear,  leaving  simply  the  deformity.  Thus,  from  the 
therapeutic  standpoint,  torticollis  may  be  classified  as  acute  and 
chronic,  the  latter  class  including  the  congenital  form. 

The  sternomastoid  is  the  muscle  that  is  usually  involved  pri- 
marily, both  in  the  congenital  and  acquired  forms;  thus,  in 
typical  torticollis  the  head  is  drawn  somewhat  forward  and  is 
inclined  toward  the  contracted  muscle,  while  the  neck  is  pushed, 
as  it  were,  away  from  the  contraction  (Fig.  438)  ;  the  chin  is 
slightly  elevated,  and  turned  toward  the  opposite  shoulder — an 
attitude  explained  by  the  normal  action  of  the  affected  muscle. 
IrregTilar  distortions  of  the  head,  as  posterior  or  anterior  tor- 
ticollis due  to  contraction  of  muscles  other  than  the  sterno- 
mastoid, are,  however,  not  infrequent.  These  will  be  mentioned 
in  the  consideration  of  the  forms  of  acquired  torticollis. 

Statistics. — Torticollis  is  one  of  the  less  common  deformities. 
62  new  cases  were  registered  at  the  Hospital  for  Ruptured  and 
Crippled  in  1909. 

Acquired  torticollis  is  by  far  the  more  frequent,  as  is  shown 
by  the  fact  that  of  507  cases  but  87  were  supposed  to  be  of  con- 
genital origin. 

671' 


672  OBTHOPEDIC  SUFiGEBY. 

Of  the  87  congenital  cases  46  were  in  females  and  the  con- 
traction was  of  the  left  side  in  38  of  the  58  cases  in  which  the 
affected  side  was  specified.  Of  the  entire  number  of  cases  avail- 
able for  comparison  246  were  in  females  and  198  in  males;  in 
236  instances  the  contraction  was  on  the  left  and  in  196  on  the 
right  side  of  the  neck.  From  these  statistics  it  would  appear 
that  the  deformity  is  somewhat  more  common  in  females  than 
in  males,  and  that  the  left  side  is  more  often  affected  than  the 
right. 

Congenital  Torticollis. — In  most  instances  the  deformity  of 
congenital  torticollis  is  slight  at  birth,  and  it  may  not  attract 
attention  until  the  child  supports  the  head  or  even  walks.  Thus 
it  is  often  difficult  to  distingTiish  the  congenital  form  from  the 
deformity  that  may  have  been  acquired  in  infancy,  especially 
as  the  patient  may  not  be  brought  for  treatment  until  the  dis- 
tortion has  persisted  for  several  years. 

In  early  infancy  slight  torticollis  may  be  demonstrated  by 
fixing  the  shoulder  on  the  affected  side  and  drawing  the  head 
forcibly  in  the  opposite  direction, .  when  the  shortened  muscle 
becomes  prominent  beneath  the  skin,  evidently  restricting  the 
range  of  motion.  In  most  instances  the  sternal  division  of  the 
muscle  appears  to  be  more  shortened  than  the  clavicular  portion. 

In  exceptional  cases  the  deformity  even  in  infancy  may  be 
extreme,  and  it  may  be  accompanied  by  well-marked  asymmetry 
of  the  face  and-  even  by  distortion  of  the  skull.  In  this  class 
the  shortening  may  involve  all  the  lateral  tissues,  both  anterior 
and  posterior.  If  asymmetry  is  present  at  birth  it  increases 
somewhat  with  growth.  Even  in  the  acquired  form  it  often 
appears  soon  after  the  onset  of  the  deformity,  becoming  more 
marked  with  its  continuance.  Its  cause  is  the  constrained  atti- 
tude, the  restriction  of  normal  use,  and  consequently  of  the 
blood  supply,  combined  with  the  tension  upon  the  tissues  of  the 
face,  as  is  evidenced  by  the  fact  that  it  becomes  less  noticeable 
after  the  eleformity  has  been  corrected. 

In  the  well-marked  cases  of  long  standing,  whether  congenital 
or  acquired,  the  face  on  the  affected  side  is  shorter  and  fiatter, 
the  nose  and  the  corner  of  the  mouth  and  the  eyelids  even  are 
drawn  downward,  and  the  skull  shows  evidence  of  atrophy  and 
deformity. 

Secondary  distortions  also  appear  in  the  trunk  in  chronic 
cases.  These  are  rotation  of  the  spine  to  compensate  for  the 
lateral  distortion  of  the  head  and   an  increase  in  the  dorsal 


CONGENITAL   AND   ACQUIRED    TORTICOLLIS. 


673 


kyphosis,  "round  shoulders."  Among  the  minor  secondary 
deformities  upward  bowing  of  the  clavicle  caused  by  the  tension 
of  the  contracted  muscle  may  be  mentioned  (Fig.  437). 

When  the  deformity  is  marked  or  of  long  standing  the  head 
and  neck  following  the  compensatory  convexity  of  the  cervical 
spine  are  displaced  toward  the  opposite  shoulder  (Fig.  438). 
This  displacement  relaxes  in  some  degree  the  contracted  tissues, 
consequently  the  lateral  distortion  of  the  head  is  lessened. 

Fig.  437. 


Left   torticollis,   apparently   of   congenital    origin,    showing   the   secondary   distor- 
tions of  head  and  face. 


The  compensatory  deformities  that  have  been  indicated  are 
slight  in  infancy,  but  they  develop  in  later  childhood,  for  in 
many  instances  the  shortened  muscle  ceases  to  grow;  thus,  an 
original  shortening  of  half  an  inch,  as  compared  to  its  fellow, 
may  be  increased  to  two  or  more  inches  in  later  years.  This 
fact  emphasizes  the  importance  of  treatment  as  soon  as  may  be 
possible  after  distortion  is  discovered. 

As  has  been  stated,  the  important  contraction  is  usually  of  the 
sternomastoid  muscle,  but  if  the  deformity  is  uncorrected  all  the 
lateral  tissues  become  shortened. 

Typical  wryneck  caused  by  shortening  of  the  sternomastoid 
43 


674 


OBTEOFEDIC  SUBGERY. 


muscles  is  by  far  tlie  most  common  form  of  congenital  torticollis, 
but  occasionally  cases  are  seen  in  which  the  head  is  but  slightly 
inclined  to  one  side  and  in  which  the  shortening  appears  to  in- 
volve the  lateral  tissues  in  general  rather  than  a  particular 
muscle.  In  rare  instances,  although  the  deformity  resembles 
that  of  typical  torticollis,  the  gTeatest  shortening  will  be  found 
to  be  of  the  posterior  muscles  on  one  side,  particularly  of  the 

Fig.  438. 


Right  torticollis,  showing  the  displacement  of  the  head  toward  the  opposite  side. 


trapezius  and  the  levator  angidi  scapulEe.  Thus  the  scapular 
may  be  elevated  and  tilted  forward.  This  form  of  torticollis 
appears  to  be  one  variety  of  congenital  elevation  of  the  scapula. 
(See  page  230.)  Torticollis  due  to  defective  development  of  the 
upper  extremity  of  the  spine  is  a  rare  deformity  that  does  not 
require  special  description. 

Etiology.. — It  may  be  assumed,  disregarding  the  possible  influ- 
ence of  hereditary  predisposition,  that  congenital  torticollis  is,  in 
most  instances,  caused  by  a  constrained  or  fixed  position  in  the 
uterus  for  a  longer  or  shorter  time  l^efore  birth.  It  is,  in  fact, 
a  simple  distortion,  and  that  it  has,  in  the  majority  of  cases,  no 
deeper  significance  is  proved  by  the  fact  that  it  may  be  easily 


CONGENITAL   AND  ACQUIEED    TOETICOLLIS.  675 

and  completely  cured  by  simj)le  division  or  elongation  of  the 
contracted  tissues. 

Haematoma  of  the  Stemomastoid  Muscle  as  a  Possible  Cause  of 

Torticollis.- — During  difficult  delivery,  fibres  of  the  muscle  are 
ruptured,  usually  in  the  upper  or  middle  third  of  the  anterior 
border,  hemorrhage  follows,  which  in  turn  is  surrounded  by  an 
encapsulating  area  of  inflammatory  material.  This  forms  a 
firm,  cylindrical  tumor  in  the  substance  of  the  muscle,  which  be- 
comes noticeable  about  two  weeks  after  birth,  or  at  least  this  is 
the  time  when  it  is  usually  discovered  by  the  mother.  As  a  rule, 
the  tumor  is  not  sensitive  to  pressure ;  it  may  or  may  not  be 
accompanied  by  restriction  of  motion  in  the  direction  causing 
tension  on  the  muscle.  The  tumor  remains  for  from  three  to 
six  months,  when  it  usually  disappears,  leaving  no  trace  of  its 
presence. 

The  theory  of  Stromeyer  is  that  congenital  torticollis  is 
usually  caused  by  rupture  of  the  muscle  and  by  myositis  about 
the  hsematoma  that  may  involve  and  ultimately  destroy  a  large 
part  of  the  substance  of  the  muscle,  replacing  it  with  fibrous 
tissue,  which,  contracting,  causes  deformity. 

This  theory  is  extremely  improbable  for  the  following  reasons : 

1.  Rupture  of  muscle  elsewhere  is  practically  never  followed 
by  myositis  and  contraction. 

2.  It  has  been  demonstrated  by  Heller^  that  it  is  impossible 
to  cause  myositis  and  contraction  by  any  form  of  injury  to  the 
muscles  of  animals  unless  it  be  combined  with  actual  infection 
with  pyogenic  germs. 

3.  Most  of  the  cases  of  congenital  torticollis  seen  soon  after 
birth  present  no  evidence  of  hsematoma  or  injury,  viz. :  In  7  of 
55  cases  of  supposed  congenital  torticollis,  investigated  by  the 
writer,  there  was  a  history  of  injury  at  birth.  In  48  cases  no 
mention  was  made  of  injury.  In  the  7  cases  referred  to  the 
deformity  was  accompanied  by  haematoma  or  there  was  a  history 
of  a  swelling,  apparently  of  this  nature ;  but  in  2  of  these  the 
haematoma  was  coincident  with  intrauterine  shortening  of  the 
muscle. 

4.  Cases  of  haematoma  of  the  stemomastoid  muscle  are  not, 
as  a  rule,  followed  by  torticollis.  Seven  consecutive  cases  of 
hsematoma  were  examined  by  the  Avriter  with  special  reference 
to  this  point.  In  all  the  evidence  of  violence  in  delivery  was 
clear.     Two  were  delivered  by  forceps,  3  were  breech  presenta- 

'  Heller,  Deutsch.  Zeits.  f .  Chir.,  Bd.  xlix.,  H.  2  and  3,  S.  234. 


676  OBTHOPEDIC  SUBGEBY. 

tions,  and  in  2  version  was  performed.  In  1  case  an  arm  was 
broken  and  in  another  paralysis  resulted  from  injury  to  the 
brachial  plexus.  Six  of  the  children  lived  until  the  swelling  had 
nearly  or  entirely  disappeared,  and  in  none  did  torticollis  ac- 
company or  follow  hsematoma. 

5.  In  certain  cases  a  congenitally  shortened  muscle  may  be 
ruptured  at  delivery;  thus  the  hsematoma  is  simply  a  complica- 
tion of  torticollis,  not  its  cause.  Bruns^  has  reported  such  a 
case,  and  two  others  have  been  observed  by  the  writer,  in  one  of 
which  club-foot  was  present  also. 

6.  Hard  tumors  of  the  sternomastoid  muscle  are  not  always 
the  result  of  injury;  myositis  may  be  of  syphilitic  origin  appar- 
ently occurring  in  intrauterine  life.  In  other  instances  tumors 
of  fibrous  or  sarcomatous  nature  have  been  removed  from  the 
substance  of  the  muscle.  Sixteen  cases  in  which  cartilaginous 
nodules,  apparently  of  congenital  origin,  were  found  in  the 
muscle  have  been  reported.^ 

One  may  conclude  then  that  congenital  torticollis  in  the 
majority  of  cases  is  of  intrauterine  origin.  If  it  follows  in- 
jury at  birth  it  is  probably  an  indirect  result  of  local  pain,  dis- 
comfort and  irritation  of  the  nerves  or  of  an  actual  infectious 
inflammation  of  the  injured  part  rather  than  an  effect  of  the 
absorption  of  effused  blood. 

Pathology, — In  the  ordinary  type  of  congenital  torticollis,  as 
demonstrated  at  operations  on  children,  the  substance  of  the 
affected  muscle  or  muscles  is  simply  lessened  in  amount,  and 
there  is  a  disproportionate  area  of  tendinous  substance  as  com- 
pared to  the  contractile  tissue.  In  other  instances  the  muscle 
may  be  almost  entirely  replaced  by  fibrous  tissue  or  it  may  be 
traversed  by  fibrous  bands,  or  patches  of  scar-like  tissue  may 
be  distributed  throughout  its  substance.  These  degenerative 
changes,  considered  to  te  evidences  of  pre-existing  myositis,  are 
probably  more  common  among  the  acquired  than  the  congenital 
form,  and,  as  a  rule,  they  are  found  only  in  cases  of  long  stand- 
ing. Secondarily  all  the  lateral  tissues  of  the  neck  are  shortened 
to  correspond  to  the  habitual  attitude,  and  the  compensatory 
curvatures  of  the  spine  in  time  become  fixed,  so  that  torticollis 
may  be  classed  as  one  of  the  causes  of  scoliosis. 

Acquired  Torticollis.- — Acquired  torticollis  is  an  aft'ection  of 

early  life,  at  least  80  per  cent,  of  the  cases  beginning  in  the  first 

ten  years  of  life. 

'  Zent.  f.  Chir.,  1891,  No.  26. 

"  Leugemaun,  Beitr.  z.  klin.  Chir.,  Bd.  xxx.,  H.  1. 


CONGENITAL  AND  ACQUIBED   TOBTICOLLIS.  677 

As  has  been  stated,  congenital  torticollis  is  usually  a  painless 
shortening  of  the  muscles,  while  acquired  torticollis  is,  as  a  rule, 
a  painful  affection  secondary  to  injury  or  disease  of  some  of  the 
structures  of  the  neck,  which  causes  irritation  of  the  peripheral 
nerves  and  active  contraction  of  the  neighboring  muscles.  Thus, 
as  a  rule,  the  number  of  muscles  involved  in  the  deformity  is 
gTeater  than  in  the  congenital  form ;  for  example,  in  the  ordinary 
form  of  acquired  wryneck  both  the  trapezius  and  the  sterno- 
mastoid  are  contracted ;  and  irregiilar  forms  of  distortion  caused 
by  spasm  of  other  muscular  gToups  are  not  uncommon. 

Varieties.- — The  varieties  of  acquired  torticollis  may  be  clas- 
sified conveniently  as  follows : 

1.  The  simple  or  mechanical  form  due  to  scar  contraction  fol- 
lowing destruction  of  the  skin  or  deeper  tissues,  as  from  burns 
or  disease. 

2.  Acute  torticollis  caused  by  direct  irritation  of  the  muscle, 
by  injury,  by  inflammatory  affections  of  the  surrounding  parts, 
combined  in  most  instances  with  irritatioii  of  the  peripheral 
nerves,  which  causes  reflex  contraction  of  certain  muscles  or 
muscular  groups. 

3.  Spasmodic  Torticollis. — A  form  of  convulsive  spasm,  "  a 
disorder  of  the  cortical  centres  for  rotation  of  the  head." 
(Walton.) 

4.  Irregular  Forms  of  Torticollis. — Paralytic,  ocular,  psy- 
chical and  the  like. 

The  first  class,  that  due  to  scar  contraction,  needs  only  to  be 
mentioned. 

Etiology  of  Acute  Torticollis. — The  second  class  is  the  most 
important  form  of  torticollis,  both  as  to  frequency  and  as  to  its 
effect  in  causing  permanent  distortion.  Of  this  gToup,  one  of 
the  most  common  and  at  the  same  time  the  least  important  form 
is  the  simple  stiff  neck,  supposed  to  be  due  to  cold  or  to  muscu- 
lar rheumatism.  Its  onset  is,  in  childhood,  sometimes  accom- 
panied by  slight  fever  and  general  discomfort ;  the  affected 
muscle  is  somewhat  sensitive  to  pressure  and  motion  or  tension 
causes  discomfort.  The  distortion,  in  great  part  voluntary  and 
accommodative,  is  of  short  duration  as  a  rule.  Strains  and 
direct  injury  of  the  muscles  of  the  neck  may  cause  deformity, 
which  usually  disappears  when  the  local  sensitiveness  has  sub- 
sided. Traumatic  hsematomata,  similar  to  those  caused  by 
injury  at  birth,  are  sometimes  observed  in  older  subjects.  These 
usually  disappear  after  a  time,  leaving  no  trace  of  their  presence. 


678  OBTHOPEDIC  STJEGEEY. 

Anotlier  form  of  torticollis  is  secondary  to  cellulitis  and  to 
infiltration  following  the  breaking  down  of  tuberculous  cervical 
glands.  This  may  become  a  permanent  distortion  if  the  defor- 
mity is  allowed  to  persist  or  if  the  tissues  of  the  neck  are  injured 
by  the  suppurative  process. 

By  far  the  most  important  variety  of  this  class  is  the  dcute 
spastic  torticollis  due  to  active  tonic  contraction  of  one  or  more 
of  the  muscles  of  the  neck.  The  exciting  cause  of  the  spasm 
appears  to  be  irritation  of  the  peripheral  nerves  in  the  naso- 
pharynx or  in  its  neighborhood,  and  the  muscles  most  often 
aifected  are  those  supjDlied  in  part  by  the  spinal  accessory  nerve. 
Thus,  torticollis  of  this  form  may  follow  tonsillitis,  pharyngitis, 
measles,  diphtheria  and  the  like.  It  may  be  preceded  by  "  tooth- 
ache" or  "earache,"  or  it  may  be  an  accompaniment  of  what 
appears  to  be  the  ordinary  form  of  stiff  neck  or  of  enlarged  or 
suppurating  cervical  glands.  In  this  form  the  torticollis  is 
caused  directly  by  tonic  contraction  of  the  muscles.  Reflex 
spasm  of  this  character  is,  however,  often  associated  with  distor- 
tion, due  primarily  to  injury  of  the  neck  or  to  some  local  inflam- 
matory process,  so  that  a  sharp  distinction  between  the  divisions 
of  this  second  class  is  impossible.  Many  of  the  patients  are 
known  to  be  of  a  nervous  temperament,  and  overstudy,  anxiety, 
sudden  shock,  and  the  like  are  considered  to  be  predisposing 
causes. 

This  variety  of  acquired  torticollis  completely  overshadows  in 
importance  all  other  forms,  as  is  indicated  by  the  statistics  of 
212  cases  treated  at  the  Hospital  for  Ruptured  and  Crippled, 
in  which  the  cause  seemed  to  be  apparent.  Of  the  212  cases  181 
may  be  fairly  assigned  to  this  class. 

The  apparent  exciting  causes  of  cases  of  acquired  torticollis 
treated  at  the  Hospital  for  Ruptured  and  Crippled  are  shown 
in  the  following  table : 

Enlarged  cervical  glands ...  14       "  Cold  in  the  neck " 5 

Suppurating  cervical  glands.  41       Eheumatism    18 

Scarlet  fever   14       Vaccinia    1 

Diphtheria    7      Fever 6 

Mumps    6       Malaria   5 

Measles   2       Injury  by  the  neck,  r 35 

Sore-throat   8       Ehaehitis    3 

Suppurative  otitis 3       Syphilis 1 

Toothache     6       Cicatricial  contraction 3 

Cellulitis  of  the  neck 2                        Total 181 

Furuncle  of  the  neck 1 


CONGENITAL   AND  ACQUIBED    TOBTICOLLIS.  679 

Torticollis  associated  with  chorea     4 

Torticollis  associated  with  epilepsy    1 

Torticollis  associated  with  cortical  irritation   5 

Torticollis  associated  with  hysteria     1 

Torticollis  associated  with  meningitis     .  •. 1 

Torticollis  associated  with  hemiplegia    3 

Spasmodic  torticollis 8 

' '  Functional  torticollis  " 8 

Total 31 

Symptoms  of  Acute  Torticollis. — As  a  rule,  the  distortion  of 
the  neck,  slight  at  first,  is  more  noticeable  at  night  than  in  the 
morning;  it  then  gradually  increases  until  the  deformity  be- 
comes fixed.  In  other  instances  the  onset  is  sudden,  sometimes 
accompanied  by  fever. 

As  has  been  stated,  in  most  instances  several  muscles  are  more 
or  less  involved  in  the  contraction,  particularly  the  sternomastoid 
and  the  trapezius,  and  in  such  cases  the  deformity  is  more 
marked  and  persistent  than  when  the  sternomastoid  is  alone 
affected.  Less  often  the  contraction  is  of  the  posterior  group, 
"posterior  torticollis"  (Fig.  441),  the  head  being  tilted  back- 
ward and  the  chin  turned  more  toward  the  opposite  side  than 
in  the  typical  lateral  form.  In  other  cases  the  contraction  ap- 
pears to  affect  the  small  muscles  that  control  the  joints  at  the 
ujDper  extremity  of  the  spine,  when  the  head  may  be  tilted  for- 
ward with  but  slight  lateral  inclination,  resembling  closely, 
except  in  the  history,  the  symptomatic  wryneck  of  Pott's  dis- 
ease. In  rare  instances  the  muscles  on  both  sides  of  the  neck 
may  be  contracted  simultaneously  (Fig.  439).  The  affected 
muscles  are  usually  sensitive  to  manipulation  and  attempted 
rectification  of  the  deformity  causes  extreme  pain  and  is  resisted 
by  the  patient.  The  child  is,  as  a  rule,  nervous  and  irritable ; 
it  often  complains  of  neuralgic  pain  about  the  contracted  parts, 
which  is  increased  by  sudden  or  unguarded  movements  or  strain ; 
thus  "getting  the  patient  to  bed"  is  often  a  tedious  proceeding, 
because  of  the  difficulty  of  supporting  the  head  comfortably 
with  the  pillows.        ^ 

In  many  instances  the  affection  is  of  short  duration ;  in  others 
particularly  those  in  which  the  reflex  spasm  is  aggravated  by 
local  inflammatory  processes,  there  appears  to  be  but  little  ten- 
dency toward  recovery.  In  such  cases,  after  several  weeks  or 
months,  the  local  pain  and  sensitiveness  may  subside,  together 
with  the  active  spasm,  but  the  deformity,  caused  by  adaptive 
shortening  of  the  muscles  and  fascia,  aggravated  in  some  in- 
stances by  actual  myositis,  persists.     The  muscles  atrophy  and 


680 


OETHOPEDIC  SUBGEEY. 


degenerate  and  j)resent  at  a  later  stage  the  same  pathological 
appearances  that  are  fonnd  in  the  congenital  form. 

Diagnosis. — Torticollis  is  most  often  confounded  with  Pott's 
disease  and  in  its  acute  form  there  may  be  some  difficulty  in 
distinguishing  between  the  two.  The  main  points  have  been 
mentioned  already  in  connection  with  Pott's  disease.  In  acute 
torticollis  the  affection  is  of  sudden  onset,  not  j)i'eceded  by  the 
stiffness  and  neuralgic  pain  that  characterize  tuberculous  disease. 


Fig.  439. 


Fig.  440. 


Bilateral  contraction  of  the 
sternomastoid  and  trapezii  mus- 
cles.     (See  Fig.  440.) 


Bilateral   torticollis   after   treatment. 
(See  Fig.  439.) 


The  deformity  of  torticollis  is  almost  always  of  the  regular  type 
— that  is,  the  head  is  tilted  toward  the  contracted  muscles  while 
the  chin  is  rotated  in  the  opposite  direction.  The  spasm  and 
contraction  of  the  aifected  muscles  are  apparent,  and  direct 
tension  upon  them  is  painful.  If,  however,  the  tension  is  re- 
laxed by  inclining  the  head  toward  the  contraction,  movement 
of  the  head  in  other  directions  will  be  found  to  be  practically 
unrestricted. 

In  Pott's  disease  the  spasm  of  muscles  is  general,  the  de- 
formity is  not  of  a  regailar  type,  since  the  chin  often  points  to 
the  side  toward  which  the  head  is  inclined.     Steady  tension  with 


CONGENITAL   AND   ACQUIBED    TORTICOLLIS.  681 

the  aim  of  reducing  the  deformity  is  not,  as  a  rule,  painful ;  in 
fact,  it  is  often  agreeable  to  the  patient.  Finally,  the  limitation 
of  motion  cannot  be  lessened  by  inclining  the  head  toward  the 
muscle  that  seems  to  be  most  contracted,  for  the  reflex  sj^asm 
of  Pott's  disease  limits  motion  in  every  direction.  As  a  rule, 
the  diagnosis  is  easily  made,  but  in  cases  complicated  by  sup- 
puration of  the  cervical  glands  it  is  sometimes  impossible  to 

Fig.  441. 


Posterior  torticollis.     Duration  one  week. 

exclude  Pott's  disease  until  after  the  effect  of  treatment  has  been 
observed. 

Disease  of  the  cervical  spine,  other  than  tuberculous,  is  com- 
paratively rare,  and  resembles  in  its  symptoms  Pott's  disease 
rather  than  torticollis.  Arthritis  of  the  suboccipital  articula- 
tions may  be  a  manifestation  of  rheumatism ;  it  may  follow  in- 
fectious disease,  or  it  may  occur  as  an  isolated  infection.     It  is 


682  OBTHOPEDIC  SUBGERY. 

of  sudden  onset,  and  it  resembles  acute  spastic  torticollis,  ex- 
cept that  all  the  surrounding  muscles  are  affected  rather  than 
a  particular  group ;  in  fact,  but  for  the  history  it  could  not  be 
distinguished  from  tuberculous  disease  of  this  region. 

Although  the  diagnosis  of  torticollis  is  simple,  it  is  not  always 
easy  to  determine  the  muscle  or  muscles  involved  in  the  con- 
traction. The  effect  of  unilateral  contraction  of  the  different 
muscles  is  as  follows : 

The  sternomastoid  inclines  the  head  toward  the  contraction, 
displaces  it  toward  the  oj)posite  shoulder,  elevates  the  chin,  and 
turns  it  away  from  the  contracted  muscle. 

The  trapezius  has  much  the  same  action,  but  the  backward 
inclination  and  rotation  are  more  marked. 

The  action  of  the  complexus  resembles  that  of  the  trapezius, 
but  the  rotation  is  less. 

The  splenius  inclines  the  head  backward  and  toward  the  con- 
tracted muscle,  but  does  not  turn  the  chin  in  the  opposite  direc- 
tion. 

The  scaleni  have  the  same  action,  except  that  the  head  is  in- 
clined forward. 

As  has  been  stated,  in  acute  torticollis  several  muscles  are 
often  involved,  but  the  spasm  is  usually  greater  in  one  or  in 
one  group  than  in  another.  The  seat  of  greatest  contraction 
may  be  determined  by  the  deformity,  by  the  evident  spasm  that 
resists  reposition,  and  by  the  local  sensitiveness  on  palpation. 
As  a  rule,  when  the  primary  contraction  is  of  the  posterior  group 
the  deformity  is  more  marked  than  in  other  forms.  Bilateral 
contraction  of  the  muscles  is  rare,  but  it  is  occasionally  seen 
(Fig.  439). 

Treatment. — The  treatment  varies  according  to  the  cause  and 
with  the  duration  of  the  deformity.  Excluding,  for  the  j)resent, 
the  rare  and  irregular  forms  of  wryneck  there  are,  from  the 
remedial  standpoint,  two  forms  of  torticollis: 

1.  The  chronic  fol"m,  in  which  the  local  pain  and  sensitive- 
ness are  absent,  but  in  which  there  is  resistant  deformity.  As 
has  been  stated,  congenital  torticollis  is  included  in  this  class. 

2.'  The  acute  form,  in  which  the  distortion  is  of  short  dura- 
tion and  in  which  permanent  contraction  may  be  prevented. 

The  Treatment  of  Chronic  Torticollis.  By  Manipulation. — Con- 
genital torticollis,  if  of  moderate  degree,  nmj  be  overcome  in 
early  infancy  by  methodical  stretching  of  the  contracted  parts. 
One  person  fixes  the  arm  and  another  draws  the  head  gently  but 


CONGENITAL   AND   ACQUIBED    TOBTICOLLIS.  683 

firmly  in  the  direction  opposed  to  the  contraction,  over  and  over 
again,  meanwhile  massaging  the  tissues  of  the  neck.  The  proce- 
dure should  be  repeated  several  times  a  day;  it  causes  slight 
momentary  discomfort  if  properly  performed,  but  this  ceases 
when  the  stretching  is  discontinued.  Care  should  be  taken  also 
that  the  posture  may,  as  far  as  jDossible,  favor  the  reduction  of 
the  deformity ;  thus  while  the  child  is  in  the  mother's  arms  the 
head  should  be  supported,  and  when  asleep  the  pillow  may  be 
arranged  in  a  manner  to  prevent  the  improper  position.  In  this 
way  the  torticollis  may  be  entirely  corrected  or  its  progress  may 
be  checked  until  more  effective  treatment  is  indicated. 

Hsematoma. — This  should  be  treated  by  massage  with  some 
bland  ointment ;  if  it  is  accompanied  by  deformity  the  manipu- 
lation already  described  should  be  employed. 

In  the  great  majority  of  cases  of  congenital  torticollis  the 
patient  is  not  brought  for  treatment  until  the  deformity  has 
become  an  eyesore  to  the  parents.  The  contracted  muscle  is 
then  usually  an  inch  shorter  than  its  fellow,  the  disparity  in- 
creasing, as  a  rule,  with  the  growth  of  the  child.  In  such  cases 
the  immediate  correction  of  the  deformity  is  indicated,  and  this 
implies  in  most  instances  division  of  the  contracted  parts  by  sub- 
cutaneous tenotomy  or  by  open  incision. 

By  Subcutaneous  Tenotomy.. — If  the  deformity  is  comparatively 
slight  and  if  the  contraction  seems  to  be  limited  to  the  sterno- 
mastoid  muscle,  and  particularly  to  its  sternal  portion,  one  may 
hope  to  overcome  the  most  resistant  part  of  the  contraction  by 
the  subcutaneous  operation.  Aside  from  the  possibility  of 
wound  infection,  which  at  the  present  time  is  an  argiiment  of 
very  little  weight,  subcutaneous  tenotomy  has  the  advantages  of 
simplicity,  apparent  freedom  from  the  danger  which  parents 
associate  with  an  operation,  and  it  leaves  no  scar.  It  is  inade- 
quate, however,  for  the  correction  of  advanced  cases. 

The  patient  and  the  instruments  having  been  prepared  as  for 
an  ordinary  operation,  a  sand-bag  is  placed  beneath  the  shoulders 
and  the  head  is  inclined  so  that  the  contracted  muscle  is  thrown 
into  relief  beneath  the  skin.  The  sternal  insertion  of  the  tendon 
is  seized  with  two  fingers  and  the  tenotome  is  inserted  beside  it 
and  passed  beneath  it  at  a  point  about  an  inch  above  the  sternum. 
It  is  then  divided  by  a  sawing  motion  of  the  knife.  Division  of 
the  tendon  in  this  situation  is  practically  free  from  danger,  and 
in  the  slighter  degrees  of  deformity  one  can  by  vigorous  manipu- 
lation and  forcible  traction  overcome  the  resistance  offered  by 


684  .  OETHOPEDIC  SUBGEBY. 

tlie  other  tissues.  If  bands  of  fascia  resist  tlie  correction,  they 
may  be  divided  by  superficial  nicking  with  the  tenotome  in  the 
lateral  region  of  the  neck.  As  a  rule,  however,  in  cases  of  this 
type  the  open  incision  is  to  be  preferred,  as  the  contracted  parts 
may  be  divided  without  danger  of  injury  to  the  bloodvessels  and 
nerves  in  this  neighborhood. 

By  the  Open  Method.. — The  skin  should  be  made  tense  by  draw- 
ing it  upward.  The  incision  should  begin  about  an  inch  above 
the  clavicle,  midway  between  the  clavicular  and  sternal  inser; 
tions  of  the  muscle,  and  pass  downward  and  forward  following 
the  natural  folds  of  the  skin  to  the  clavicle.  In  the  milder  cases 
in  childhood  it  need  be  little  more  than  an  inch  in  length.  A 
director  may  be  passed  beneath  the  sternal  tendon,  and  on  this 
it  may  be  divided.  The  clavicular  insertion  and  the  more  re- 
sistant bands  of  fascia  may  be  divided  as  they  appear.  The 
fascia  and  skin  are  then  carefully  united  with  fine  catgut. 

In  cases  of  very  great  deformity  in  the  adult  some  of  the  pos- 
terior as  well  as  the  lateral  muscles  are  involved.  In  such  in- 
stances the  contracted  parts  may  be  divided  at  the  upper  border 
of  the  neck  through  an  incision  from  the  mastoid  process  back- 
ward along  the  lower  border  of  the  scalp,  the  scar  being  con- 
cealed by  the  hair. 

Overcorrection  of  the  Deformity. — The  object  of  treatment  is 
not  only  to  correct  the  deformity,  but  also  to  overcome  all  re- 
striction of  motion  that  may  remain  after  the  division  of  the 
more  resistant  parts,  and  the  operation,  whether  open  or  sub- 
cutaneous, must  be  supplemented  by  a  vigorous,  methodical 
stretching  of  underlying  resistant  tissues.  Finally,  the  head 
should  be  rotated  in  the  opposite  direction,  the  aim.  being  to 
completely  overcome  the  secondary  curvature  of  the  cervical 
spine. 

It  may  be  stated  that  Lorenz  considers  it  possible  to  correct 
torticollis,  even  of  long  standing,  by  systematic  kneading  and 
stretching  vnthout  previous  division  of  the  contracted  tissues, 
but  the  use  of  so  much  force  appears  to  be  undesirable  if  by  so 
slight  an  operation  it  may  be  avoided. 

After  all  resistance  to  passive  motion  has  been  overcome  by 
vigorous  manipulation  the  head  should  be  fixed  during  the 
process  of  repair  in  the  overcorrected  position.  Thus  in  the 
treatment  of  typical  torticollis  the  chin  should  be  turned  to  a 
point  over  the  middle  of  the  clavicle  on  the  operated  side,  and 
the  head  should  be  inclined  toward  the  opposite  shoulder,  while 


CONGENITAL   AND   ACQUIBED    TORTICOLLIS.  685 

the  neck  is  held,  in  the  median  line.  In  this  attitude  a  plaster 
bandage  should  be  applied  surrounding  the  head  and  the  thorax. 
It  should  remain  until  all  local  sensitiveness  has  disappeared, 
and  until  the  tendency  toward  deformity  has  been  checked. 
Fixation  in  the  overcorrected  position  is  very  important  in 
childhood,  as  an  aid  in  overcoming  the  deformity  habit,  but  it 
may  be  dispensed  with  in  the  treatment  of  adults  (Fig.  442). 

Fig.  442. 


Torticollis,  left,  showing  the  method  of  flxing  the  head  in  the  overcorrected 
position.      After   operation. 

The  plaster  support  is  usually  retained  from  four  to  eight 
weeks.  When  it  is  removed,  massage,  manipulation,  and  gym- 
nastic training  are  indicated.  Twice  a  day  the  head  should  be 
forced  to  the  extreme  limit  of  overcorrection.  Traction  on  the 
neck  in  self-suspension  by  means  of  the  sling  used  in  the  ajDpli- 
cation  of  the  plaster  jacket,  a  regular  system  of  exercises  for 
the  muscles  of  the  neck  and  back,  and  supervision  of  the  habitual 
postures  will  usually  assure  a  comj)lete  cure.  If,  however,  the 
deformity  habit  is  strong  so  that  the  head  has  a  marked  tendency 
to  resume  the  former  attitude,  some  support  is  indicated.     A 


686  OBTEOPEDIC  SUBGEBT. 

simple  and  effective  supjDort  is  the  jury-mast  as  used  in  the 
treatment  of  Pott's  disease  with  the  plaster  jacket  or  attached  to 
a  brace. 

As  has  been  stated,  the  necessity  for  support,  provided  the 
deformity  has  been  thoroughly  overcorrected,  depends  upon  the 
care  that  is  to  be  exercised  in  the  after-treatment.  When  exer- 
cises and  massage  can  be  efficiently  employed,  the  support  is  not 
essential.  In  other  cases  it  may  be  worn  for  several  months 
with  advantage. 

The  principles  of  the  treatment  of  the  chronic  or  painless 
form  of  torticollis  that  have  been  outlined  apply  to  the  acquired 
as  well  as  to  the  congenital  form,  when  adaptive  shortening 
has  replaced  active  contraction.  Acquired  torticollis  is,  in  most 
instances,  however,  a  preventable  deformity;  thus  operative 
treatment  would  be  rarely  required  had  the  patient  received 
proper  treatment. 

The  Treatment  of  Acute  Torticollis. — The  insignificant  form  of 
torticollis  called  stiff  neck  may  be  treated  by  hot  applications; 
a  firm,  wide,  thick  collar  of  flexible  cotton  stiffened  by  several 
layers  of  adhesive  plaster  is  an  agreeable  support  in  the  more 
painful  cases. 

In  acute  spastic  torticollis  the  cramp-like  contraction  of  the 
muscles  is  secondary  to  irritation  elsewhere.  This,  if  possible, 
should  be  removed,-  and,  as  has  been  stated,  the  general  con- 
dition of  the  patient  often  requires  treatment  as  well.  But  the 
important  indication  is  to  support  the  head  in  order  to  relieve 
the  pain  and  to  correct  the  distortion.  In  the  early  stage  the 
support  of  the  collar  that  has  been  described  may  be  sufficient, 
but,  as  a  rule,  patients  of  this  class  are  not  seen  until  the  dis- 
tortion has  persisted  for  weeks  or  months  even,  so  that  a  more 
efficient  form  of  support  is  required — such  is  the  plaster  jacket 
and  jurymast.  The  elastic  tension  of  this  appliance  overcomes 
the  spasm  and  relieves  the  discomfort  and  apprehension  which 
have  lowered  the  vitality  of  the  patient  (Fig.  41).  If  the  spasm 
is  the  result  of  the  irritation  of  enlarged  or  suppurating  cervical 
glands,  as  is  often  the  case,  the  rest  afforded  by  the  brace  is  an 
effective  treatment  of  the  cause  as  well  as  of  its  effect,  and  if 
suppuration  is  present  this  support  is  most  convenient  for  the 
dressing  that  may  be  required.  When  the  acute  symptoms  and 
the  deformity  have  been  relieved,  manipulation  and  exercises 
may  be  employed  in  the  manner  already  described. 

In  cases  of  longer  standing,  particularly  when  the  posterior 


CONGENITAL   AND  ACQUIRED    TORTICOLLIS.  687 

muscles  are  involved,  the  deformity  may  be  forcibly  corrected 
under  anaesthesia,  and  the  head  may  then  be  fixed  in  a  plaster 
dressing  in  the  manner  already  described.  This  treatment  may 
be  employed  at  an  earlier  stage  in  selected  cases.  As  a  rule, 
when  deformity  has  been  allowed  to  persist  for  six  months  or 
more,  its  rectification  will  require  division  of  the  more  resistant 
tissues. 

Spasmodic  Torticollis. — Spasmodic  torticollis,  a  form  of  con-- 
vulsive  spasm  of  the  muscles  of  the  neck  that  is  somewhat  simi- 
lar in  its  general  characteristics  to  writer's  cramp,  must  not  be 
confounded  with  the  acute  torticollis  of  childhood,  in  which 
tonic  s-pasm  of  the  affected  muscles,  due  usually  to  some  well- 
defined  irritation  of  the  peripheral  nerves,  is  the  characteristic. 
Spasmodic  torticollis  is  an  affection  of  adult  life.  Of  32  cases 
collected  by  Richardson  and  Walton,^  but  two  were  in  patients 
less  than  twenty  years  of  age.  The  sexes  are  equally  liable  to 
the  affection,  and  the  contraction  is  as  frequent  on  one  side  as 
on  the  other. 

The  onset  of  the  affection  is  usually  gradual.  The  first  symp- 
toms are  most  often  stiffness  and  discomfort  in  the  muscles  of 
the  neck ;  a  ''  drawing  sensation "  and  a  momentary  twitch- 
ing or  slight  contraction  which  draws  the  head  to  one  side. 
These  symptoms  increase  slowly  until  the  head  is  habitually 
inclined  in  the  attitude  of  torticollis.  For  a  time  the  patient 
can  correct  the  position  voluntarily,  or  by  supporting  the  head 
with  the  hand  can  restrain  the  twitching  of  the  muscles,  but  in 
well-established  cases  the  head  is  persistently  inclined  to  one  side 
and  the  convulsive  sj)asm  is  uncontrollable.  This  latter  symp- 
tom is  the  most  marked  peculiarity  of  the  affection ;  at  intervals 
the  muscles  begin  to  twitch,  and  the  head  finally  drawn  by  the 
convulsive  contraction  into  an  attitude  of  extreme  deformity. 
As  the  muscles  most  often  affected  are  the  sternomastoid  and 
trapezius  the  attitude  is  usually  one  of  typical  torticollis.  The 
spasmodic  clonic  contractions  may  involve  the  muscles  of  the 
face  or  of  the  chest  even.  They  are  more  marked  when  the 
patient  is  excited  or  when  sudden  movements  are  necessary.  As 
a  rule,  patients  complain  of  neuralgic  pain  in  the  head  and  neck, 
aggravated  by  the  cramp-like  contractions. 

Etiology  and  Pathology.- — The  etiology  is  obscure.  Many  of 
the  patients  present  a  neurotic  family  or  personal  history,  and 
overwork,  shock  to  the  nervous  system,  and  the  like  are  cited  as 

^  American  Journal  of  the  Medical  Sciences,  January,  1895. 


688  OETHOPEDIC  SUBGEEY. 

predisposing  causes.  The  affection  has  been  compared  to 
writer's  cramp,  as  in  certain  instances  the  spasm  appeared  to  be 
caused  bj  constrained  positions  of  the  head  necessitated  by  cer- 
tain occupations,  aggravated,  it  may  be,  by  the  strain  of  de- 
fective eyesight. 

The  affected  muscles  may  be  hypertrophied  from  constant 
activity,  and  in  the  later  stages  of  the  affection  they  are,  as  a 
rule,  permanently  shortened.  jSTo  characteristic  changes  in  the 
nerves  or  in  the  central  nervous  system  have  been  recorded. 

Prognosis. — There  is  little  tendency  toward  spontaneous  re- 
covery. As  a  rule,  the  spasm  becomes  more  constant  and  other 
muscles  become  involved. 

Treatment. — It  is  perhaps  unnecessary  to  state  that  the  general 
condition  of  the  patient  and  the  possible  local  and  general  causes 
of  the  spasm  should  receive  consideration.  As  a  rule,  however. 
the  patient  will  have  exhausted  both  constitutional  and  local 
treatment  before  coming  under  observation. 

In  the  mild  and  early  cases  the  avoidance  of  predisposing 
causes  combined  with  massage,  systematic  muscle  training,  and 
in  exceptional  instances  mechanical  support  may  be  of  service; 
but  in  the  chronic,  severe,  and  persistent  cases  of  this  class  the 
resection  of  nerves  supplying  the  affected  muscles  has  alone 
proved  to  be  efficient.  If  the  spasm  is  limited  to  the  sterno- 
mastoid  and  trapezius  muscles,  resection  of  the  spinal  accessory 
nerve  may  be  sufficient ;  but  if  other  muscles  are  involved  or  if 
the  spasm  recurs  after  the  original  operation,  the  removal  of  the 
posterior  branches  of  the  upper  cervical  nerves,  together  with 
extensive  division  of  the  contracted  muscles  upon  the  same  side 
and  sometimes  upon  the  opposite  side  also,  may  be  required. 

Resection  of  the  spinal  accessory  nerve  was  first  performed 
by  Campbell  de  Morgan,  of  London,  in  1866,  and  since  then  the 
operation  has  been  repeated  many  times  by  other  surgeons,  with 
temporary  or  permanent  benefit  to  the  patients.  According  to 
Petit,  of  26  patients  so  treated  13  were  cured  and  7  were  per- 
manently improved.  In  5  others  the  benefit  was  but  temporary, 
and  1  died  from  erysipelas  following  the  operation.^ 

Opeeatigjs''  of  the  Section  of  Spiral  Accessory  Xekve. 
—The  spinal  accessory  nerve  passes  downward  and  backward 
from  the  jugular  foramen  and  enters  the  anterior  border  of  the 
sternomastoid  muscle  at  a  point  about  one  and  a  half  inches 
below  the  tip  of  the  mastoid  process.  At  this  point  it  should  be 
'L 'Union  Medicale,  July  9,  1897. 


CONGENITAL   AND   ACQUIBED    TORTICOLLIS.  689 

exposed.     Dr.  E.  Eliot,  Jr.,  from  a  special  study  of  the  course 
and  relations  of  the  nerve,  suggests  the  following  method:^ 

"  The  incision  should  be  generous,  for  the  nerve  is  situated  at 
a  considerable  depth,  and  should  extend  from  the  mastoid  proc- 
ess above  downward  to  one  or  two  inches  beyond  the  angle  of 
the  jaw.  The  anterior  edge  of  the  sternomastoid  should  then  be 
exposed.  In  the  upper  part  of  the  wound  the  posterior  and 
inferior  portion  of  the  parotid  gland  may  have  to  be  drawn  for- 
ward, although  usually  it  does  not  overlap  the  muscle.  When 
this  is  done  it  is  comparatively  easy  to  expose  by  blunt  dissec- 
tion" th«  transverse  process  of  the  atlas,  as  it  lies  directly  below 
the  mastoid  process  above,  while  immediately  in  front  of  this 
bony  prominence,  and  running  downward  and  forward  from  the 
mastoid  process  toward  the  angle  of  the  jaw  is  the  posterior  belly 
of  the  digastric.  Behind  this  lie  the  main  vessels  of  the  neck, 
with  the  spinal  accessory  nerve  emerging  from  the  jugular  for- 
amen, and  the  operator  is  certain  that  no  harm  can  be  done  to 
these  structures  as  long  as  he  remains  superficial  to  the  digastric 
belly,  which  in  its  turn  lies  at  a  considerable  depth — in  fact,  at 
about  the  level  of  the  transverse  process  of  the  atlas. 

"  Owen  and  Petit  have  drawn  attention  to  the  fact  that  the 
nerve  usually  enters  the  mastoid  muscle  at  a  point  opposite  the 
angle  of  the  jaw.  I  have  found,  however,  in  a  large  majority  of 
cases  that,  on  leaving  the  internal  jugular  it  assumes  a  definite 
relationship  with  the  transverse  process  of  the  atlas.  ISTever 
above  it,  sometimes  directly  over  it,  usually  a  fraction  of  an  inch 
in  front  of  its  most  prominent  part,  the  nerve  may  easily  be  de- 
tected in  the  small  amount  of  connective  tissue  that  envelops  it, 
and  from  this  point  to  its  entrance  into  the  belly  of  the  muscle 
it  may  be  isolated  with  safety,  and  treated  by  any  suitable  pro- 
cedure. If,  exceptionally,  it  should  escajDe  detection  the  anterior 
border  of  the  muscle  should  be  drawn  sharply  backward  at  a 
point  opposite  the  angle  of  the  jaw,  the  nerve  in  this  way  put 
on  the  stretch,  and  by  blunt  dissection  in  the  adipose  tissue  that 
separates  the  under  surface  of  the  muscle  from  the  sheath  of  the 
vessels  the  nerve  may  be  readily  exposed.  Usually  the  nerve 
passes  from  under  the  posterior  belly  of  the  digastric,  at  a  point 
just  in  front  of  the  transverse  process  of  the  atlas,  to  a  point  on 
the  deep  surface  of  the  muscle  just  behind  its  anterior  margin 
opposite  the  angle  of  the  inferior  maxilla.  It  is  sometimes 
accompanied  by  a  small  artery  and  vein,  the  latter  easily  visible, 

^  Annals  of  Surgery,  May,  1895. 
44 


690  ORTHOPEDIC  SUEGEBT. 

the  former  a  brancli  of  the  occipital.  Earely  the  nerve  lies  at  a 
considerable  distance  from  the  transverse  process  of  the  atlas; 
in  one  case  as  much  as  half  an  inch  anteriorly.  Here  the  nerve 
conld  be  fonnd  at  its  entrance  into  the  muscle,  the  landmark  of 
the  transverse  process  having  failed  to  localize  its  situation." 

Eichardson  suggests  that  if  the  nerve  is  not  readily  found  its 
position  may  be  ascertained  by  drawing  the  finger-nail  firmly 
across  the  bottom  of  the  v^ound,  a  sharp  contraction  following 
pressure  upon  it.  The  nerve  having  been  isolated  a  section  of 
an  inch  should  be  removed.  Richardson  advises  in  addition 
vigorous  stretching  of  both  extremities.  After  division  of  the 
nerve  the  sj)asmodic  contraction  relaxes  and  the  muscles  become 
flaccid,  permitting  the  normal  position  of  the  head,  or  if  the 
deformity  has  become  permanent  the  contracted  parts  may  be 
divided  as  in  the  ordinary  form.  Fixation  of  the  head  is  not, 
as  a  rule,  required.  The  operation  should  be  supplemented  by 
massage  and  by  muscle-training.  If  the  spasm  has  been  con- 
fined to  the  muscles  supplied  by  the  spinal  accessory  nerve,  the 
treatment  may  be  permanently  successful,  but  in  many  instances 
the  spasm  may  recur  in  other  muscles.  Of  these,  the  posterior 
group  of  the  opposite  side  is  more  often  affected,  and  a  similar 
operation  for  resection  of  the  posterior  branches  of  the  upper 
cervical  nerves  may  be  indicated.  This  has  been  performed 
with  success  by  Smith,  of  London ;  Keen,  Richardson,  and 
others.  According  to  Smith, -^  the  operation  should  be  conducted 
as  follows :  An  incision  is  carried  downward  from  the  occiput 
about  three  inches  in  length,  parallel  to  and  one  inch  from  the 
spinous  processes.  It  is  continued  through  the  trapezius  to  the 
edge  of  the  splenius. 

The  complexus  is  then  divided  and  the  posterior  branches  of 
the  nerves  are  exposed ;  those  of  the  three  upper  nerves  which 
supply  the  posterior  rotators  are  then  resected. 

Keen^  operates  in  a  somewhat  different  manner,  by  a  trans- 
verse incision  two  and  a  half  inches  in  length  from  the  middle 
line  of  the  neck  on  a  level  with  a  point  one-half  an  inch  below 
the  level  of  the  lobule  of  the  ear.  The  trapezius  is  divided  trans- 
versely, afterward  the  complexus,  care  being  taken  to  spare  the 
great  occipital  nerve.  The  posterior  branch  of  the  second  cer- 
vical nerve  is  then  resected ;  the  suboccipital  nerve  is  then  looked 
for  in  the  suboccipital  triangle,  traced  down  to  the  spine,  and 

^  Spasmodic  Wryneck,  London,  1891. 
-  Annals  of  Surgery,  January,  1891. 


CONGENITAL   AND  ACQUIEED    TOBTICOLLIS.  691 

divided.  The  external  trunk  of  the  posterior  division  of  the 
third  occipital  nerve  is  then  exposed  below  the  great  occipital 
and  divided  close  to  the  bifurcation  of  the  nerve  trunk ;  thus  the 
nerve  supply  of  the  chief  posterior  rotators,  the  splenius  capitis, 
the  rectus  capitis,  jDosticus  major,  and  the  obliquus  inferior  is 
removed. 

The  paralysis  that  follows  even  such  extensive  operations 
seems  to  inconvenience  the  patient  but  slightly,  while  the  relief 
from  deformity  and  from  the  constant  spasm  is  a  more  than 
sufficient  compensation  for  whatever  weakness  or  disability  may 
result. 

The  following  are  the  conclusions  of  Richardson  and  Walton  :^ 

1.  Palliative  treatment,  whether  by  drugs,  apparatus,  or  elec- 
tricity, will  rarely  prove  successful  in  well-established  spas- 
modic torticollis, 

2.  Massage  may  prove  of  value  in  comparatively  recent  cases. 

3.  Resection  affords  practically  the  only  rational  remedy. 

4.  Operation  on  the  spinal  accessory  nerve  may  afford  relief, 
even  if  other  muscles  than  the  sternocleidomastoid  are  affected. 
On  the  other  hand,  the  affection  previously  limited  to  the  sterno- 
cleidomastoid may  spread  to  other  muscles  in  spite  of  this 
operation. 

5.  'No  fear  of  disabling  paralysis  need  deter  us  from  recom- 
mending operation,  as  the  head  can  be  held  erect  even  after  the 
most  extensive  resection. 

6.  The  most  common  combination  of  spasm  is  that  involving 
the  sternomastoid  on  one  side  and  the  posterior  rotators  on  the 
other,  the  head  being  held  in  the  position  of  sternomastoid  spasm 
with  the  addition  of  retraction  through  the  greater  power  of  the 
posterior  rotators. 

7.  It  seems  advisable  in  most  cases  to  give  preference  to  the 
resection  of  the  spinal  accessory  as  the  preliminary  procedure. 

In  a  later  communication  Richardson  and  Walton^  report 
very  satisfactory  final  results  on  cases  treated  by  resection  of 
nerves  suj)plying  the  muscles  that  were  affected  by  the  spasm  on 
one  or  both  sides,  combined  with  complete  division  of  the  muscles 
as  well,  when  permanent  contraction  was  present. 

Kalmus''  has  reviewed  the  literature  of  the  subject.  In  11 
cases  of  simple  stretching  of  the  spinal  accessory  nerve  3  were 

^  Annals  of  Surgery,  January,  1891. 
-  American  Journal  of  the  Medical  Sciences,  1896. 

^  Zur  Operativ  Beliand.  Caput.  Obst.  Spasticum,  Beitrage  zur  klin.  Chir., 
1900,  Bd.  xxiv. 


692  OBTHOPEDIC  SUEGEBY. 

cured.  In  68  cases  the  nerve  was  resected ;  of  these  23  were 
cured  and  20  were  improved.  In  4  there  was  no  improvement 
and  in  1  the  j^atient  died.  In  15  cases  the  resection  of  the  nerve 
was  supplemented  by  division  of  cervical  nerves ;  10  of  these 
were  cured  and  3  were  improved.  In  2  others  the  sternomastoid 
muscle  was  divided. 

Irregular  and  Exceptional  Forms  of  Torticollis. — Paralytic 
Torticollis, — One  or  more  of  the  muscles  of  the  neck  may  be 
paralyzed,  as  from  anterior  poliomyelitis,  and  thus  a  deformity, 
due  at  first  to  simple  weakness  and  later  to  the  permanent  effects 
of  the  disability,  may  be  the  result. 

Diphtheritic  Paralysis  and  Torticollis. — The  muscles  of  the  neck 
may  be  involved  in  paralysis  following  diphtheria.  In  this 
form  the  trapezii  muscles  are,  as  a  rule,  affected,  so  that  the 
head  droops  forward,  but  occasionally  the  paralysis  may  be  ac- 
companied by  contraction  of  one  of  the  sternomastoids.  The 
history,  the  evident  weakness,  and  the  paralysis  of  the  soft 
palate  or  other  parts,  which  is  often  present,  usually  make  the 
diagnosis  clear. 

Cervical  Opisthotonos. — In  the  course  of  certain  forms  of  dis- 
ease of  the  nervous  system,  for  example,  cerebrospinal  or  basilar 
meningitis,  the  head  may  be  drawn  backward  by  spasm  of  the 
posterior  muscles.  A  slight  degree  of  the  same  deformity  is 
sometimes  seen  in  ill-nourished  infants  not  suffering  from 
serious  disease.  This  and  the  preceding  distortion  are  of  some 
importance,  because  they  may  be  mistaken  for  symptoms  of 
Pott's  disease  and  they  have  been  described  in  that  connection. 

Rhachitic  Torticollis. — During  the  course  of  acute  rhachitis, 
particularly  when  the  characteristic  deformity  of  the  lower  part 
of  the  spine  is  well-marked,  the  head  may  be  tilted  backward 
usually  as  a  compensatory  attitude,  but  occasionally  slight  spasm 
of  the  posterior  muscles  may  increase  the  distortion;  so,  also, 
when  lateral  deviation  of  the  spine  is  present  due  to  rhachitis 
the  neck  may  participate  in  the  deformity  as  in  other  forms  of 
rotary  lateral  curvature.  This  is  not  torticollis,  however,  in  the 
proper  sense. 

Ocular  Torticollis.- — The  head  may  l)e  habitually  held  in  a  dis- 
torted attitude  because  of  defective  vision  or  irregularity  in  the 
action  of  the  muscles  of  the  eyes.  This  is,  however,  rather  an 
improper  attitude  than  a  variety  of  true  torticollis^   (Fig.  177). 

'  Medical  Xews,  Juue  11.  18f)8,  p.  772. 


CONGENITAL  AND  ACQUIBED  TORTICOLLIS.  693 

Psychical  Torticollis. — A  distortion  of  the  head,  apparently 
due  to  the  inability  of  the  patient  to  control  the  muscles  of  the 
neck,  has  been  described  by  Brissaud.^  The  deformity  is  not 
due  to  muscular  spasm,  since  it  can  be  corrected  by  the  pressure 
of  a  finger  on  the  head.  The  condition  is  called  by  Brissaud  a 
local  paralysis  of  the  -will — a  form  of  neurosis  allied  to  neuras- 
thenia, epilepsy,  and  functional  spasm. 

1  These  de  Paris,  1894. 


CHAPTER   XX. 

DISABILITIES    AND    DEFOEMITIES    OF    THE    FOOT. 

GENERAL  DESCRIPTION  OF  THE  FOOT  AND  OF  ITS 
FUNCTIONS. 

The  function  of  the  foot  is  twofold :  to  serve  as  a  passive 
support  of  the  weight  of  the  body,  and  as  an  active  lever  to  raise 
and  propel  it.  For  the  proper  performance  of  these  functions 
it  is  constructed  to  permit  elasticity  under  pressure,  and  an 
alternation  of  attitudes  under  strain,  that  protect  it  from  injury. 

The  Arches. — The  most  noticeable  peculiarity  of  the  foot  is 
the  arrangement  of  its  arches.  As  has  been  suggested  by  Ellis 
and  others,  the  construction  and  shape  of  the  arched  part  of  the 

Fig.  443. 


Longitudinal  section  of  the  cast  of  the  arch  at  the  point  A  in  Fig.  M4.  A, 
the  astragalonavicular  junction;  Bj  the  internal  tuberosity  of  the  os  caleis  ;  C, 
the  head  of  the  first  metatarsal  bone. 

foot  may  be  better  understood  by  considering  it  as  half  of  the 
arch  formed  by  the  two  feet.  This  complete  arch  may  be  demon- 
strated by  making  an  imprint  of  the  apposed  feet  in  plaster-of- 
Paris.  The  plaster  cast  which  represents  it  will  appear  in  shape 
somewhat  like  an  inverted  saucer,  the  part  of  each  foot  that  rests 
upon  the  ground  forming  half  of  an  irregular  ring.  If  the  plas- 
ter cast  is  sawed  into  equal  sections  it  will  be  seen  that  the 
highest  or  thickest  part  of  each  division  is  at  the  astragalo- 
navicular junction;  from  this  point  the  arch  descends  sharf)ly 
to  the  tuberosities  of  the  os  caleis,  and  gradually  to  the  outer 
border,  beneath  the  cuboid  bone,  and  to  the  metatarsoj^halangeal 
joints  (Eig.  443).  A  cross-section  of  the  cast  will  show  the  con- 
tour of  what  is  sometimes  called  the  transverse  arch  (Eig.  444), 
while  the  section  through  the  long  diameter  will  demonstrate  the 
shape  of  the  longitudinal  arch.     In  descriptions  of  the  longi- 

694 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOO-T. 


695 


tudinal  arch,  it  is  often  divided  into  two  j)arts,  of  which  the  outer 
division  is  formed  by  the  os  calcis,  the  cuboid,  and  the  twp  outer 
metatarsal  bones.  Of  this  outer  arch,  the  highest  point  is  at  the 
calcaneocuboid  articulation  (Fig.  445),  ^nd  although  it  is 
normally  a  permanent  arch,  yet  the  soft  tissues  are  forced  down- 

FiG.  444. 


Cross-section  of  the  cast  of  the  arches  of  the  apposed  feet.     A,  the  internal  and 
inferior  surface  of  the  astragalonavicular  junction. 

ward  beneath  it  when  weight  is  borne,  so  that  the  outer  border 
of  the  foot  makes  an  imjDrint  throughout  its  entire  length,  as 
contrasted  with  the  inner  and  deeper  arch  formed  by  the  os 
calcis,  the  astragalus,  the  navicular,  the  cuneiform,  and  the 
three  inner  metatarsal  bones  (Fig.  446).  This  division,  al- 
though an  artificial-one,  serves  to  call  attention  to  the  fact  that 

Fig.  445. 


The  bones  of  the  right  foot,  viewed  from  the  outer  side.      (Testut,  from  Gerrish's 

Anatomy.) 

the  outer  or  lower  arch  is  more  solidly  braced,  and,  therefoi-e. 
better  adapted  for  continuous  weight  bearing  than  is  the  higher 
and  more  elastic  inner  arch. 

The  diagram  of  the  longitudinal  arch,  showing  its  sharp 
descent  from  the  highest  point  to  the  centre  of  the  heel,  indicates 
that  the  heel  is  well  adapted  for  weight  bearing,  while  the  long 
anterior  pillar  composed  of  several  bones  is  less  strong  but  more 


696 


OETHOPEDIC  SUPiGEEY. 


elastic;  thus  one  instinctively  extends  the  foot  in  descending 
stairs,  for  example,  to  avoid  the  unpleasant  jar  of  direct  shock 
received  upon  the  heel.  Of  this  anterior  pillar,  the  third  meta- 
tarsal bone  is  the  most  direct  support,  while  the  more  movable 
first  and  fifth  metatarsals,  more  under  muscular  control,  aid  in 
balancing  the  weight  and  sustaining  it  in  the  different  attitudes. 
Both  divisions  of  the  longitudinal  arch  are  permanent  arches, 
but  there  are  two  others  which  are  obliterated  under  weight — - 
one  of  these  is  that  formed  bv  the  heads  of  the  metatarsal  bones, 
the  anterior  metatarsal  arch.  In  the  unweighted  foot  the  second 
and  third  metatarsophalangeal  articulations  occupy  a  higher 
plane  than  their  fellows,  but  when  the  erect  posture  is  assumed 
the  anterior  arch  is  depressed  to  allow  the  metatarsal  heads  to 

Fig.  446. 


Tlie  bones  of  the  right  foot,  viewed  from  the  inner  side. 

Anatomy.) 


(Testut,  from  Gerrish's 


bear  their  share  of  the  weight.  The  other  arch  is  formed  by  the 
internal  border  of  the  foot,  which  curves  slightly  outward,  so 
that  when  the  two  feet  are  placed  side  by  side  an  interval  re- 
mains between  them,  widest  at  the  highest  point  of  the  longitu- 
dinal arch,  as  is  shown  in  the  diagram  by  the  upright  section 
which  divides  the  cast  of  the  two  soles  from  one  another,  the 
internal  arcli  (Fig.  444).  AYhen  the  weight  is  borne  this  curved 
contour  of  the  foot  becomes  straighter,  or  is  obliterated,  or  is 
even  transformed  to  an  arch  whose  convexity  is  internal  (Fig. 
469). 

The  Foot  as  a  Passive  Support. — The  foot  is  supported  by 
the  muscles,  by  ligaments,  and  by  the  strong  plantar  fascia  that 
covers  in  the  sole.  When  the  foot  is  actively  used  it  is  in  great 
part  supported  by  the  muscles,  but  when  it  serves  as  a  passive 
support,  as  in  standing,  the  ligaments  bear  the  greater  part  of 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.         697 

i 

the  strain,  and  its  normal  elasticity  allows  the  bearing  surface 
to  expand  as  the  arches  are  slightly  depressed.  If  this  elasticity 
is  diminished,  the  supports  of  the  arch  are  subjected  to  abnor- 
mal pressure  and  the  individual  may  suifer  from  sensitive  corns 
or  calloused  skin  beneath  the  bones  (Fig.  496).  Or  if  the  liga- 
ments permit  abnormal  expansion  the  arches  may  become  per- 
manently depressed,  and,  as  a  result,  the  range  of  motion  neces- 
sary to  the  proper  functional  use  of  the  foot  may  be  permanently 
restricted  (Fig.  474). 

It  has  been  stated  that  the  foot  broadens  and  that  the  arches 
are  slightly  depressed  under  weight ;  it  must  not  be  understood, 
however,  that  the  longitudinal  arch  is  simply  flattened  by  direct 
pressure  and  by  elongation  of  elastic  ligaments  and  fascia. 
Ligaments  and  fascia  are  not  elastic  in  this  sense,  and  they  are 
not,  in  the  normal  foot,  overstretched.  The  change  in  contour 
is  the  effect  of  normal  motion  in  the  joints  of  the  foot,  by  which 
it  is  placed  in  the  most  favorable  attitude  for  weight  bearing 
without  muscular  exertion — the  so-called  attitude  of  rest. 

Of  the  changes  of  contour  that  distinguish  the  foot  used  as  a 
passive  support  from  the  one  that  bears  no  weight,  the  most 
significant  is  the  obliteration  of  the  outward  curve  of  its  internal 
border.  This  change  is  due  to  the  fact  that  the  astragalus,  bear- 
ing the  leg,  rotates  inward  and  downward  on  the  os  calcis  until 
.  it  is  checked  by  the  resistance  of  the  ligaments  and  by  the  inter- 
locking of  the  bones.  The  head  of  the  astragalus  thus  becomes 
slightly  prominent,  the  inner  border  of  the  foot  is  depressed,  and 
an  attitude  is  attained  in  which  the  weight  of  the  body  may  be 
supported  with  but  slight  muscular  exertion.  In  this  attitude  of 
rest,  as  von  Meyer  has  exj^lained,  there  is  general  fixation  of 
joints  of  the  lower  extremity  which  makes  support  possible  with 
the  least  muscular  exertion.  The  pelvis  tilts  slightly  backward 
until  tension  is  brought  upon  the  anterior  part  of  the  capsule  of 
the  hip-joint;  the  femur  rotates  slightly  inward  on  the  tibia, 
which  in  turn  falls  slightly  inward  upon  the  everted  foot.  To 
unlock  the  joints  the  pelvis  must  be  tilted  forward  or  the  hip 
mu^t  be  flexed. 

The  Foot  in  Activity. — The  second  function  of  the  foot  is  as 
a  lever  to  raise  and  to  proj)el  the  body.  The  calf  muscles  supply 
the  power  and  the  heads  of  the  metatarsal  bones  serve  as  the 
fulcrum  on  which  the  weight  is  to  be  lifted.  When  the  foot  is 
used  as  a  lever,  it  should  be  held  in  such  relation  to  the  leg  that 
the  line  of  weight,  passing  downward  through  the  centre  of  the 


698 


OSTHOPEDIC  SUEGEEY. 


knee  and  ankle-joints,  is  continued  over  the  second  toe  or  prac- 
tically the  centre  of  the  foot.  As  the  body  is  lifted  over  the  ful- 
crum the  leg  is  turned  outward  in  its  relation  to  the  forefoot, 
because  the  inner  side  of  the  fulcrum,  formed  by  the  first  meta- 
tarsal bone,  is  longer  than  its  outer  side ;  thus  the  strain  is 
directed  toward  the  outer  and  stronger  side  of  the  foot  (Fig. 
447). 

In  the  proper  walk,  which  is  the  best  illustration  of  the  lever- 
age function,  the  feet  should  be  held  practically  parallel  to  one 
another,  so  that  the  line  of  strain  may  fall  through  the  centre  of 


Fig.  447. 


Illustrating  the  invohmtary  ad- 
duction of  the  forefoot,  due  to  the 
obliquity  of  the  bearing  surface  of 
the  metatarsus,  in  the  proper  atti- 
tude for  walking. 


The  improper  attitude  of  outward  ro- 
tation of  the  limbs  usually  accompanied 
by  eversion  of  the  feet  in  which  there 
is  disuse  of  the  leverage  function. 


the  foot.  As  one  foot  is  advanced  it  first  bears  weight  momen- 
tarily on  the* heel,  then  upon  its  outer  border;  the  heel  is  then 
raised,  and  the  body  is  lifted  over  the  toes,  the  great  toe  giving 
the  final  impulse  to  the  step,  so  that  if  the  walker  is  looked  at 
from  behind  he  appears  to  be  in-toeing  at  the  termination  of 
each  step.  Thus,  during  the  walk,  there  is  an  alternation  of 
postures,  and  the  foot,  under  muscular  control,  assumes  the 
attitudes  most  opposed  to  that  of  passive  support. 


DISABILITIES  AND  DEF0B2IITIES  OF  THE  FOOT. 


699 


Improper  Postures. — The  alternation  of  postures  and  the 
leverage  action  of  the  foot  are  bv  no  means  necessary  to  simple 
progression;  for  example,  both  feet  might  be  fixed  in  plaster 
bandages,  yet  walking  would  be  possible,  just  as  it  is  possible  on 
two  wooden  legs.  Indeed,  an  approximation  to  such  a  manner 
of  walking  is  often  seen,  in  which  the  feet  are  practically  held 
in  the  passive  attitude,  the  weight  being  borne  in  great  part 


Fig.  449. 


Fig.  450. 


Voluntary  dorsal   flexion.  Voluntary   plantar  flexion. 

In  tliese  attitudes  ttie  astragalus  moves  with  the  foot  upon  the  leg  bones,  as 
contrasted  with  adduction  and  abduction,  in  which  the  centre  of  motion  is  below 
the  astragalus. 

upon  the  heels.  Such  a  walk  is  necessarily  jarring  and  ungrace- 
ful, and  if  it  is- not  the  result  of  weakness  and  deformity  it  pre- 
disposes to  them  because  of  the  disuse  of  proper  function. 

One  means  of  making  the  leverage  function  difficult  is  the 
custom  of  turning  the  feet  outward.  Outward  rotation  of  the 
limbs  is  normal  in  the  passive  attitude  because  it  enlarges  the 
base  of  support  and  thus  relieves  the  muscles.  On  this  very 
account  it  is  the  improper  attitude  for  activity  because  the  strain 
falls  upon  the  inner  border  of  the  foot,  or  to  the  inner  side  of  the 
fulcrum,,  and  makes  the  proper  exercise  of  muscular  power  and 
alternation  of  postures  imj)ossible.  In  other  words,  the  attitude 
normal  when  the  foot  is  used  as  a  passive  support  is  abnormal 
when  it  is  in  active  use. 


700 


OETHOPEDIC  SURGES Y. 


The  Movements  of  the  Foot. — The  junction  between  the  foot 
and  the  leg  is  made  by  means  of  the  astragalus,  a  bone  which  is 
not  intimately  connected  with  either  part,  since  it  moves  upon 
''the  leg  and  upon  the  foot,  and  to  it  no  muscles  are  attached. 

The  primary  movements  of  the  foot  are  four  in  number — 
dorsal  flexion,  plantar  flexion,  adduction,  abduction. 

Simple  dorsal  and  plantar  flexion  are  confined  to  the  ankle- 
joint,  but  extreme  plantar  flexion  is  combined  with  slight  adduc- 
tion,  and  dorsal  flexion  with  abduction,  because  the  external 


Fig.  451. 


Fig.  4.52. 


Voluntary  adduction.  Voluntary  abduction. 

In  these  postures  the  foot  moves  upon  the  astragalus,  which  is  practically 
fixed  between  the  malleoli.  Adduction,  the  turning  of  the  foot  inward  in  its 
relation  to  the  leg,  is  always  accompanied  by  elevation  of  its  inner  and  depres- 
sion of  its  outer  border.  This  is  known  as  supination  or  inversion  of  the  foot. 
The  reverse  of  this  attitude — pronation  or  eversion — is  an  accompaniment  of 
abduction,  as  is  illustrated  in  the  figures. 


facet  of  the  astragalus  permits  a  greater  range  of  motion  on  the 
external  malleolus  than  that  about  the  internal  malleolus,  and 
because  the  forefoot  in  plantar  flexion  turns  downward  and 
inward  on  the  head  of  the  astragalus  and  in  the  reverse  direction 
in  dorsal  flexion. 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT. 


701 


The  range  of  motion  at  the  ankle-joint  is  from  60  to  80  de- 
grees ;  thus  dorsal  flexion  to  10  or  20  degrees  less  than  the  right 
angle,  and  plantar  flexion  to  50  to  60  degTees  more  than  the 
right  angle  (Figs.  449  and  450). 

Adduction  and  abduction  of  the  foot  are  carried  out  in  the 
mediotarsal  and  subastragaloid  joints. 

Adduction,  the  turning  of  the  foot  inward  in  its  relation  to 
the  leg,  is  always  accompanied  by  inversion  of  the  sole  because 
of  the  shape  of  the  joint  surfaces  between  the  astragalus  and 
OS  calcis,  where  the  greater  part  of  the  motion  takes   place. 


Fig.  453. 


Fig.  454. 


The  direct  dorsal  flexors. 
Tibialis  anterior  of  right  side ;  out-  Peroneus  tertius  of  right  side;  out- 

line   and    attachment    areas.       (Ger-  line    and    attachment    areas.       (Ger- 

rish.)  rish.) 

Simj)le  adduction  and  abduction  without  inversion  or  eversion 
is  possible  to  a  very  limited  extent  in  the  mediotarsal  joint. 
Its  range  may  be  tested  by  fixing  the  heel,  when  the  forefoot 
may  be  moved  slightly  from  side  to  side  upon  the  astragalus 
and  OS  calcis.  The  range  of  motion  in  the  subastragaloid 
joint  is  twice  as  free  as  in  the  mediotarsal  joint.  The  char- 
acter of  the  motion  between  the  astragalus  and  os  calcis  is 
rotation  on  an  axis  passing  through  the  upper  and  inner  part  of 
the  head  of  the  astragalus,  downward  and  outward  to  the  outer 


702 


OETHOPEDIC  SUEGEEY. 


tuberosity  of  the  os  calcis.  Thus  for  all  practical  iDurposes  ad- 
duction, inversion,  and  supination  are  synonymous  terms,  as 
are  abduction,  eversion,  and  pronation. 

In  the  movement  of  inversion  the  astragalus  is  practically 
fixed  by  the  malleoli,  and  upon  it  the  os  calcis  glides  forward,  its 
anterior  extremity  turning  slightly  inward;  its  inner  superior 


Fig.  455. 


Fig.  456. 


The  calf  muscle. 

Gastrocnemius   of  right  side  ;  outline 

and  attachment  areas.      (Gerrish.) 


The  plantar  flexor. 
Soleus  of  right  side ;  outline  and  at- 
tachment areas.      (Gerrish.) 


surface  is  elevated,  and  its  external  surface  is  depressed.  Mean- 
while the  forefoot,  attached  to  the  os  calcis,  is  carried  inward  and 
downward  about  the  head  of  the  astragalus ;  its  inner  border  is 
elevated,  and  its  outer  border  is  repressed,  so  that  the  sole  looks 
inward  and  downward.  In  this  attitude  all  the  arches  are  in- 
creased in  depth  (Fig.  451). 

In  eversion  the  bones  move  upon  one  another  in  the  reverse 
direction,  the  curves  are  lessened,  and  that  of  the  inner  border 
is  obliterated  (Fig.  452). 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


703 


SimjDle  inversion  and  eversion  can  be  carried  out  to  the  full 
extent  with  the  foot  at  a  right  angle  to  the  leg.  Complete  ad- 
duction, however,  is  only  attained  in  the  position  of  plantar 
flexion.  In  this  position  the  forefoot  is  flexed  over  the  head  of 
the  astragalus,  increasing  the  depth  of  the  arch  and  the  adduction 
permitted  at  the  ankle-joint  when  the  narrow  posterior  border  of 
the  astragalus  is  alone  in  contact  with  the  malleoli,  is  added  to 
the  adduction  which  the  joints  of  the  foot  permit. 


TzG.  457. 


Fig.  458. 


The  direct  abductors. 

Peroneus  longus  of  right  side  ;  outline        Peroneus   brevis   of  right  side  ;   outline 

and  attachment  areas.      (Gerrish.)  and  attachment  areas.      (Gerrish.) 


Extreme  abduction  is  attained  in  the  attitude  of  dorsal 
flexion,  its  extent  being  about  one-half  that  of  adduction ;  the 
entire  range  of  motion  between  the  two  extremes  being  about  45 
degrees. 

In  this  description  the  foot  is  considered  as  moving  on  the 
leg,  but  in  the  attitude  of  rest  the  foot  becomes  the  fixed  point 
and  the  astragalus  moves  upon  the  os  calcis  in  the  manner  and 
to  the  position  already  mentioned  in  the  description  of  abduc- 
tion— i.  e.,  it  slips  downward  and  forward  and  turns  inward ;  at 
the  same  time  the  anterior  extremity  of  the  os  calcis  turns 
slightly  inward  and  downward,  and  its  inner  border  is  de- 
jDressed.     Corresponding  to  this  movement,  as  the  inner  border 


704 


ORTHOPEDIC   SUEGEBY. 


Fig.  459. 


of  the  foot  becomes  straight  or  bulges  inward,  the  navicular  is 
forced  forward  and  downward  and  the  longitudinal  arch  is  de- 
pressed. As  has  been  mentioned,  the  turning  of  the  leg  inward 
and  the  corresponding  turning  of  the  foot  outward  in  its  rela- 
tion to  it  locks  in  a  manner  the  ankle-joint,  and  at  the  same 
time  throws  the  strain  upon  the  ligaments,  so  that  standing  in 
the  erect  posture  is  possible  with  but  little 
muscular  exertion  (Fig.  464). 

To  put  in  a  simpler  manner,  the  leg  sup- 
porting the  weight  of  the  body  has  a  tendency 
to  tilt  the  foot  over  toward  the  inner  side  and 
to  evert  the  sole;  thus,  under  increasing 
weight,  the  point  of  greatest  pressure  on  the 
sole  shifts  from  its  centre  and  outer  border 
toward  the  inner  border.  If,  on  the  other 
hand,  the  body  is  raised  upon  the  toes,  the 
arch  is  relieved  from  strain  and  the  weight 
falls  upon  the  front  and  outer  part  of  the 
foot.  Plantar  flexion  and  adduction  repre- 
sent, as  contrasted  with  the  passive  attitude 
of  supporting  weight,  the  attitude  of  activity 
in  which  the  foot  is  supported  and  controlled 
by  the  muscles. 

The  Function  of  the  Muscles. —  The  most! 
important  function  of  the  dorsal  flexors  is  toi 
raise  the  foot  as  it  is  swung  forward;  of  the^ 
plantar  flexors  to  lift  and  propel  the  body. 
The  difference  in  function  is  shown  by  the 
relative  strength  of  the  two  groups,  the  plan- 
tar flexors  being  flve  times  the  stronger;  in 
fact,  the  calf  muscle  (gastrocnemius  and 
soleus)  alone  is  three  times  as  powerful  as 
all  the  other  muscles  of  the  foot  combined. 
It  is  practically  the  leverage  muscle,  the 
others  serving  more  especially  to  balance  the 
foot  and  hold  it  in  its  proper  relation  to  the 
leg.  It  is  also  a  powerful  adductor  and  in- 
vertor  of  the  foot  in  the  attitude  of  plantar  flexion  (Figs.  455 
and  456). 

The  muscles  that  more  directly  support  the  inner  arch  of  the 
foot  are  the  tibialis  posticus  and  tibialis  anticus,  whose  tendons 
approach  to  their  attachments  in  front  of  the  astragalus.  The 
tibialis  anticus  supports  the  internal  border  of  the  foot  from 


■^v^ 


The  most  impor- 
tant adductor.  Tibi- 
alis posterior  of 
rigbt  side ;  outline 
and  attachment 
areas.  The  most  of 
the  muscle  is  repre- 
sented as  if  seen 
through  the  bones. 
(Gerrish.) 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.         705 

above,  and  is  the  direct  invertor  of  the  foot  in  dorsal  flexion — 
that  is,  if  unopposed  it  elevates  the  inner  border  of  the  foot, 
when  it  acts  as  a  dorsiflexor.  The  tibialis  posticus  is  the  most 
powerful  adductor  (Figs.  453  and  459).  The  extensor  longus 
hallucis  is  an  adjunct  of  the  tibialis  anticus  in  its  action  on  the 
foot  as  a  whole.  The  extensor  longus  digitorum,  including  the 
peroneus  tertius,  is  a  dorsal  flexor  and  abductor. 

The  flexor  longus  hallucis,  passing  directly  beneath  the  sus- 
tentaculum tali,  aids  in  supporting  the  weak  part  of  the  foot  and 
its  position  demonstrates  the  importance  of  the  proper  func- 
tional use  of  the  great  toe  (Fig.  463). 

The  peroneus  longus  and  brevis  support  the  outer  arch,  and 
the  former  binds  the  foot  together  and  holds  the  great  toe  firmly 
against  the  ground ;  thus  it  indirectly  supports  the  longitudinal 
arch  against  direct  pressure  (Figs.  457  and  458). 

The  peroneus  longus  is  an  abductor,  the  brevis  a  more  direct 
evertor  of  the  foot. 

The  relative  streng-th  of  the  muscles  and  their  functions  is 
indicated  in  the  following  tables:^ 

Dorsal  Flexors   of  the   Foot;    Strength   Eeckoned   in   Kilo- 
grammetres. 

Tibialis  anticus    0.871 

Extensor  longus  digitorum    0.280 

Extensor   longus    pollicis 0.155 

Peroneus   tertius    0.087 

1.393 
Plantar  Flexors. 

The   calf     /  Soleus     3.256 

muscle.        \  Gastrocnemius     2.831 

Flexor  longus  pollicis   0.218 

Peroneus  longus   0.118 

Tibialis   posticus    0.094 

Flexor  longus  digitorum    0.078 

Peroneus  brevis    0.055 

6.650 

The  Foot  Considered  as  a  Mechanism. — In  the  study  of  the 
deformities,  and  particularly  of  the  functional  weaknesses  of  the 
foot,  one  must  never  lose  sight  of  the  fact  that  it  is  a  mechanism, 
and  that  its  deformities  and  disabilities,  its  relative  strength  or 
weakness,  can  be  appreciated  only  by  comparing  it  with  the 
normal  standard.  Marked  deformity  or  distortion  is  evident 
at  a  glance,  even  though  the  apparatus  is  not  in  use,  but  func- 
tional ability  can  be  estimated  only  by  the  manner  in  which 
active  work  is  performed. 

^  Ueber  die  Arbeitsleistung  der  auf  die  Fussgelenke  Wirkenden  Muskeln, 
E.  Fick,  Leipzig. 
45 


706 


OBTHOPEDIC  SUEGEEY. 


As  has  been  stated,  the  foot  is,  in  activity,  a  lever,  by  means 
of  which  the  weight  of  the  body  is  lifted  and  propelled.  If  it  is 
loosely  constructed  or  insufficiently  supported  by  the  ligaments, 
it  cannot  be  properly  controlled  by  the  muscles.  If,  on  the  other 
hand,  the  muscular  power  is  insufficient,  the  weight  of  the  body 
cannot  be  lifted  and  properly  balanced  upon  it.  The  structure 
of  the  foot  may  be  normal,  and  its  muscles  may  be  of  normal 
strength,  jet  the  strain  placed  upon  it  may  be  disproportionately 


Fig.  460. 


Fig.  461. 


Extensor  proprius  hallucis  of  right 
side ;  outline  and  attachment  areas. 
(Gerrish.) 


Extensor  longus  dlgitorum  of  right 
side ;  outline  and  attachment  areas, 
i.tierrish.j 


great.  The  strain  may  be  overweight  of  body,  or  the  overwork 
of  a  laborious  occupation,  but  more  often  the  foot  is  overworked 
because  it  is  weakened  by  compression  and  consequent  distor- 
tions and  because  it  is  subjected  to  mechanical  disadvantages  in 
the  performance  of  its  functions,  by  the  assumption  of  improper 
attitudes. 

One  of  the  most  common  of  such  attitudes  is,  as  has  been 
mentioned,  that  of  turning  the  feet  outward  in  walking;  for  as 
the  fulcrum  is  displaced  outward,  the  strain  falls  through  the 
inner  and  weaker  side  of  the  foot.  As  a  consequence  there  is, 
to  a  greater  or  less  degree,  disuse  of  the  active  leverage  function, 
the  foot  being  used  somewhat  as  if  it  were  a  movable  pedestal. 


DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT. 


707 


(Fig.  447).  This  posture  is  usually  associated  with  abduction 
of  the  foot,  the  passive  attitude  that  predisposes  to  pain  and 
weakness. 

The  disuse  of  the  active  function  may  be  unnecessary,  just 
as  the  outward  rotation  of  the  limbs  with  which  it  is  associated 


Fig.  462. 


Fig.  463. 


Flexor  longus  digitorum  of  right 
side ;  outline  and  attachment  areas. 
The'  muscle  is  represented  as  seen 
from  in  front  through  the  bones. 
(Gerrish.) 


Flexor  longus  hallucis  of  right 
side ;  outline  and  attachment  areas. 
The  muscle  is  represented  as  seen 
from  the  front  through  the  bones. 
(Gerrish.) 


is  a  habit,  a  habit  that  is  often  the  result  of  improper  teaching. 
On  the  other  hand,  the  habitual  assumption  of  the  passive  atti- 
tude may  be  induced  by  injury  or  disease  of  the  foot,  or  by  corns- 
or  bunions,  or  by  improper  shoes.  Tor  under  such  conditions- 
the  strain  of  the  leverage  function  increases  the  discomfort ;  con- 
sequently it  is  discontinued.  It  must  not  be  inferred  that  such, 
improper  attitudes  lead  directly  to  weakness  and  discomfort,, 
for  in  most  instances  an  ungraceful  carriage  and  gait  are  the- 
only  ill  effects.     The  improper  attitudes  must,  however,  lessen 


708 


OETEOPEDIC  SUPiGEBY. 


the  power  and  resistance  of  the  foot,  and  they  must  be  reckoned, 
therefore,  among  the  important  predisposing  causes  of  dis- 
ability. 

The  passive  attitude,  it  will  be  remembered,  is  the  attitude 
of  abduction  or  rest,  in  which  the  ligaments  bear  the  greater 
part  of  the  strain  and  in  which  the  arches  of  the  foot  are  de- 
pressed or  obliterated. 


Fig.  464. 


Fig.  465. 


An  attitude  that  simulates  the  flat- 
foot.      (See  Fig.  466.) 


Fig.  465  compared  with  Fig.  464 
illustrates  the  voluntary  protection 
of  the  foot  from  overstrain. 


THE  WEAK  FOOT. 

Synon3ans.^ — Splaj-foot,  flat-foot. 

The  introductory  pages  of  this  chapter  lead  naturally  to  the 
consideration  of  the  most  important  of  the  acquired  disabilities 
of  the  foot/  a  disability  whose  characteristic  in  the  mildest  and 

^  In  1909,  1713  new^  cases  of  weak  foot  were  registered  in  the  outpatient 
department  of  the  Hospital  for  Euptured  and  Crippled  in  a  total  of  7296 
new  patients,  23  per  cent. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


709 


Typical  "  flat-foot  "  of  moderate  de- 
gree, illustrating  the  component  ele- 
ments of  abduction  and  depression  of 
the  arch. 


ill  the  most  advanced  type  is  the  persistence  of  the  passive  atti- 
tude of  abduction,  or  an  approximation  to  it,  in  place  of  normal 
alternation  of  posture.  Disuse  of  function  is  followed  by  restric- 
tion of  motion,  particularly  in  the  range  of  adduction  and  plan- 
tar flexion,  and  finally  by  de- 
formity, a  deformity  that  is  ^^^-  '^^^• 
simply  an  exaggeration  of  the 
normal  posture  assumed  when 
the  foot  supports  weight  (i'ig. 
464).  This  is  the  so-called 
flat-foot  (Fig.  466).  At  first 
glance  it  may  seem  that  the 
depression  of  the  arch  is  the 
most  noticeable  peculiarity  in 
a  characteristic  case  of  flat- 
foot,  and  that  the  popular 
name  is,  therefore,  an  appro- 
priate one.  On  closer  exami- 
iiation,  however,  it  will  appear 
that  the  foot  is  not  flat  because 
its  "keystone  has  sunk,"  but 

that  the  lowered  arch  is  caused  by  lateral  displacement  (ab- 
duction) .  This  fact  may  be  demonstrated  by  adducting  the  foot 
sufficiently  to  restore  approximately  the  normal  relation  between 
it  and  the  leg,  a  movement  which  will  restore  its  normal  contour. 
The  deformity  then  may  be  analyzed  as  follows : 
1.  The  leg  is  displaced  inward,  so  that  the  weight  falls  upon 
the  inner  side  of  the  foot.  2.  The  leg  is  rotated  inward  so 
that  a  line  drawn  through  its  centre,  prolonged  from  the  crest 
of  the  tibia,  instead  of  falling  over  the  second  toe,  now  points 
inside  the  great  toe,  or  even  over  the  centre  of  the  internal 
border  of  the  foot  (Figs.  466  and  469). 

It  has  been  stated  that  under  normal  conditions,  in  the  act  of 
passive  weight  bearing,  the  astragalus  rotates  downward  and 
inward  upon  the  os  calcis,  depressing  its  anterior  and  internal 
border  until  the  movement  is  checked  by  the  strong  ligaments 
connecting  the  bones,  the  calcaneonavicular,  the  deltoid,  and  the 
interosseus ;  in  other  words,  in  the  passive  attitude  the  leg  has  a 
tendency  to  slip  downward  and  inward  from  off  the  foot.  In  the 
weak  foot  of  advanced  grade  this  simulating  attitude  has  become 
an  actual  deformity,  for  the  normal  movement  has  become  so 
exaggerated  by  the  distention  of  the  ligaments  and  by  the  weak- 


710 


OBTROPEDIC  SUBGEBY. 


ness  of  the  supporting  muscles  that  an  actual  subluxation  is 
present.  The  astragalus  has  rotated  and  slipped  far  to  the  inner 
side  of  its  normal  position,  to  an  attitude  of  exaggerated  rotation 


Fig.  468. 


The  relation  of  the  astragalus  to  the 
OS   calcis. 


The    relation    of    the    astragalus    and 
OS  calcis  in  flat-foot. 


and  plantar  flexion,  so  that  its  head  can  be  plainly  felt  on  the 
internal  border  of  the  foot.  The  anterior  extremity  of  the  os 
calcis  is  depressed  and  is  turned  slightly  inward  and  its  internal 
border  is  lowered  (Fig.  468). 

The  navicular  has  been  depressed  with  the  head  of  the  astrag- 
alus, although  to  a  less  degree,  it  has  been  forced  farther  away 
from  the  os  calcis,  and  the  entire  inner  border  of  the  foot  is 
lowered.  Thus  the  depression  of  the  arch  is  always  accompanied 
and  preceded  by  a  bulging  inward  of  the  inner  side  of  the  foot. 

The  typical  flat-foot  is,  as  it  were,  broken  in  the  centre  (Fig. 
466),  the  posterior  division  having  turned  inward  and  down- 
ward, while  the  forefoot  is  forced  downward  and  outward.  The 
dislocation  may  be  so  extreme  that  the  entire  sole  of  the  foot  rests 
upon  the  ground,  and  a  callus  even  may  be  found  at  the  point 
that  usually  represents  the  highest  point  of  the  arch,  which  now 
supports  the  greatest  burden. 

In  this  change  of  relation  between  the  bones  the  arched  part 
of  the  foot  or  waist  appears  much  broader  than  normal,  even 
broader  than  the  front  of  the  foot ;  the  heel  projects,  the  external 
malleolus  is  depressed  and  carried  forward  by  the  rotation  of 
the  leg,  and  is  much  less  prominent  than  normal ;  the  internal 
malleolus  is  more  prominent,  and  with  the  astragalus  it  over- 
hangs the  bearing  surface  of  the  sole.  The  entire  mechanism  is 
out  of  gear;  its  motion  is,  therefore,  very  much  restricted.  It 
is  manifestly  impossible  for  the  patient  to  adduct  the  forefoot — 
that  is,  to  turn  it  inward  alx)ut  the  head  of  the  displaced  astrag- 
alus.    Plantar  flexion  is  also  much  limited,  because  of  the  per- 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


711 


sistent 
flexion 
appear 
and  sli 
466). 
The 
every 


adduction  and  plantar  flexion  of  the  astragalus.     Dorsal 

on  the   other  hand,   even   if   actually  restricted,   may 

to  be  abnormally  free,  because  the  forefoot  is  abducted 

ghtly  dorsiflexed  upon  the  head  of  the  astragalus  (Fig. 

disability  and  its  accompanying  deformity  are  found  in 
jrade  of  severity.     Discomfort  usually  begins  when  the 


Fig.  469. 


Fig.  470. 


Weak  feet,  showing  the  inward 
rotation  of  the  legs  when  the  ab- 
ducted feet  are  placed  side  by  side, 
indicating  an  attitude  of  persistent 
abduction. 


Weak  feet,  arches  not  depressed. 


strain  upon  the  muscles  is  disproportionate  to  their  strength,  and 
it  is  increased  when  the  ligaments  begin  to  give  way  under 
strain,  allowing  the  bones  to  occupy  an  abnormal  relation  to  one 
another.  It  is  evident,  therefore,  that  the  individual  in  whose 
foot  the  arch  is  well-formed  and  whose  ligaments  are  firm,  will 
suffer  from  the  symptoms  of  strain  long  before  the  arch  has 


712  OBTHOPEDIC   SUBGEEY. 

been  depressed ;  also,  that  the  lateral  inward  bulging,  character- 
istic of  abduction,  must  be  very  great  before  the  arch  is  com- 
pletely flattened.  In  this  type  the  prominent  deformity  is 
lateral  displacement  (valgus).  On  the  other  hand,  if  the  indi- 
vidual has  inherited  a  low  arch,  or  if,  as  the  result  of  weakness 
in  early  life,  the  arch  has  been  depressed  or  has  never  formed, 
accommodative  changes  in  the  joints  will  have  taken  place  dur- 
ing growth,  so  that  the  flat-foot  of  this  type  will  not  be  attended 
with  as  much  change  in  its  relation  to  the  leg,  and,  therefore, 
disturbance  of  function,  as  in  the  typical  case  that  has  been  de- 
scribed. This  latter  class  of  cases  exemplifies  the  popular  type 
of  flat-foot  that  may  exist  without  pain  or  disability,  and  in 
which  the  most  noticeable  peculiarity  is  the  obliteration  of  the 
arch  (planus).     (Contrast  Figs.  4Yl  and  472.) 

In  certain  instances  abnormal  laxity  of  ligaments  permits  de- 
formity of  the  valgus  type  when  weight  is  borne,  yet  the  foot, 
controlled  by  efficient  muscles,  may  be  apparently  normal  in 
fuBctional  ability,  while  in  other  cases  in  which  the  ligaments 
are  normal  and  yet  are  subjected  by  insufficient  muscular  pro- 
tection to  overstrain,  disability  and  pain  may  precede  noticeable 
deformity. 

It  is  evident  that  the  lowering  of  the  arch  is  of  secondary  im- 
portance in  the  deformity,  and  that  the  popular  significance  of 
flat-foot,  as  an  inherited  and  irremediable  weakness,  is  most 
misleading.  Yet  it  seems  to  have  governed  the  treatment  of  the 
disability  until  very  recently.  On  the  one  hand,  the  early  cases 
were  overlooked  because  the  foot  was  not  flat,  while  those  in 
which  the  deformity  was  more  advanced  were  either  neglected 
or  were  treated  by  simple  supports  beneath  the  arch  or  by  opera- 
tion without  regard  to  the  loss  of  function,  and,  therefore,  with- 
out hope  of  ultimate  cure. 

As  has  been  stated,  there  is  one  feature  common  to  every  grade 
of  the  so-called  flat-foot :  the  foot  regarded  as  a  mechanism  is 
weak  as  compared  to  the  normal  standard — weak  because  of  the 
persistence  of  the  attitude  of  rest  and  relaxation,  as  contrasted 
with  that  of  activity  and  strength,  and  weak  because  the  proper 
relation  between  the  power  and  the  fulcrum  is  changed.  Even 
the  inherited  flat-foot  or  the  flat-foot  which  has  never  caused 
symptoms  is  weak  in  the  sense  that,  in  use,  it  lacks  the  spring 
and  elasticity  characteristic  of  the  perfect  machine.  The  term 
weak  foot  may  he  used,  then,  to  include  all  types  of  the  dis- 
ability. 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         713 

111  one  weak  foot  the  arch  has  disappeared  (Fig.  466)  ; 
in  another  it  is  lowered ;  in  a  third  the  arch  is  of  normal  depth, 
(Fig.  4Y0).  In  one  case  the  deformity  appears  only  under 
weight;  in  another  the  foot  is  held  rigidly  in  the  deformed 
position  by  muscular  spasm.  In  one  instance  there  may  he 
great  deformity  without  pain ;  and  in  another  disabling  weak- 
ness and  pain  without  noticeable  deformity.  In  one  case  the 
foot  is  unable  to  perform  its  functions  because  of  its  inherent 
weakness ;  in  another  the  disability  may  be  due  simply  to  the 
improper  use  of  a  normal  structure  but  there  is  one  charac- 
teristic common  to  all,  a  persistence  of  the  passive  attitude  of 
abduction. 

Pathology. — Assuming  the  foot  to  have  been  normal  before  it 
began  to  break  down,  it  is  evident  that  extreme  deformity  could 
not  have  been  acquired  without  adaptive  changes  in  its  internal 
structure.  In  a  general  way  these  changes  have  been  indicated 
already.  The  ligaments  on  the  internal  aspect  of  the  foot  and  of 
the  ankle-joint  are  weak  and  distended;  the  unused  portions  of 
the  articular  surfaces  of  the  joints  may  be  denuded  of  cartilage, 
while  new  facets  may  have  formed  to  accommodate  the  changed 
relations  of  the  bones.  For  example,  the  external  malleolus  may 
be  in  direct  contact  with  the  os  calcis ;  evidences  of  injury  and  of 
abnormal  jDressure  may  be  found  in  the  thickened  periosteum,  in 
formation  of  osteophytes,  while  the  internal  structure  of  the 
bones  has  been  changed  in  adaptation  to  the  new  conditions. 
The  disused  muscles,  particularly  the  plantar  flexors  and  adduc- 
tors, have  become  atrophied,  as  evidenced  by  the  shrunken  calf. 
The  muscles  on  the  inner  border  of  the  foot  have  been  over- 
stretched, while  those  on  the  upper  and  outer  part  have  become 
shortened  and  contracted  in  accommodation  to  the  habitual  pos- 
ture. Such  a  foot  represents  an  extreme,  it  may  be  an  irreme- 
diable degree  of  deformity ;  but  in  by  far  the  greater  proportion 
of  the  cases  the  pathological  changes  have  not  advanced  to  a 
stage  that  precludes  successful  treatment. 

Etiology.- — The  early  symptoms  are  caused  by  fatigue  and 
strain  of  the  muscles  working  at  a  disadvantage,  and  the  later 
symjDtoms  are  explained  by  the  injury  to  which  the  overstrain 
has  subjected  the  mechanism. 

This  theory  accounts  for  the  fact  that  the  weak  foot,  although 
very  common  in  childhood,  does  not,  as  a  rule,  cause  noticeable 
symptoms  until  adolescence,  when  the  weight  and  strain  put 
upon  it  are  increased.     It  explains  why  the  foot,  which  may  be 


714  OETHOPEDIC  SUBGEBT. 

fairly  normal  in  structure,  breaks  down  ofteii  in  later  adoles- 
cence or  early  adult  life  when  the  continuous  strain  of  regular 
occupation  is  undertaken.  It  is  evident,  also,  that  an  occupa- 
tion that  induces  a  persistence  of  the  passive  attitude,  that  of 
waiters,  cooks,  and  bartenders,  for  example,  exposes  the  feet  to 
greater  strain  than  one  which  encourages  alternation  of  postures. 
And  that  the  symptoms  are  likely  to  be  more  severe  and  the 
deformity  to  be  greater  among  those  who  are  obliged  to  labor 
than  among  those  who  are  not.  Overwork  or  strain,  of  occupa- 
tion or  otherwise,  may  be  temporarily  disproportionate  because 
of  general  weakness,  as,  for  example,  during  pregnancy  or  after 
recovery  from  exhausting  disease ;  or  because  of  local  injury  or 
disease  of  the  foot  itself,  which  weakens  it  directly  or  indirectly 
by  inducing  improper  attitudes.  This  theory  explains  why 
there  is  no  constant  relation  between  the  degree  of  deformity 
and  the  severity  of  the  symptoms,  for,  although  all  weak  feet 
are  mechanically  weak,  yet  all  weak  feet  are  not  necessarily 
painful  or  deformed.  Pain  is  not  caused  because  the  foot  is 
flat ;  it  is  a  symptom  of  strain  and  injury  and  of  progressive  de- 
formity. The  progress  of  the  deformity  may  be  temporarily  or 
permanently  checked  at  any  stage,  either  by  removal  of  the 
exciting  causes  or  because  of  the  resistance  of  the  tissues ;  then 
the  pain  intermits  or  ceases., 

This  conception  of  the  foot  as  a  mechanism,  of  which  grades 
of  efficiency  may  be  recognized,  has  a  great  advantage,  since  it 
enables  one  to  perceive  wherein  a  foot  is  weak,  even  though  the 
weakness  causes  no  symptoms  whatever,  and  thus  to  prevent 
discomfort  and  deformity  by  the  recognition  and  treatment  of 
its  predisposing  causes. 

Statistics.- — A  brief  analysis  of  1000  cases  of  so-called  flat- 
foot  treated  at  the  Hospital  for  Ruptured  and  Crippled  will 
represent  fairly  the  points  of  general  interest  in  this  class  of 
cases : 

The  Age  and  Sex  of  the  Patients. 

Males.          Females,  Total. 

Ten    years    or    less 68                 30  98 

Ten  to  fifteen    112                  87  199 

Fifteen   to   twenty    ...144                 83  227 

Twenty  to  twenty-five    94                 53  147 

Twenty-five  to  thirty 68                 41  109 

More  than  thirty 132                 88  220 

618  382  food 
Foot  aflfected:    right,  133;   left,  138;   both,  729. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.         715 

In  58  cases  the  cause  of  the  disability  appeared  to  be  injury, 
and  in  65  instances  it  was,  apparently,  due  to  the  so-called 
rheumatoid  diseases.  The  symptoms  usually  appear  first  in 
one  foot,  and,  as  a  rule,  they  are  at  all  times  more  marked  on 
one  side.  Of  569  instances,  in  which  the  duration  of  symptoms 
was  recorded,  it  was  six  months  or  less  in  409. 

It  may  be  noted  that  in  more  recent  statistics  than  the  above 
which  were  compiled  for  the  first  edition  of  this  work,  the  dis- 
ability is  practically  equally  divided  between  the  sexes,  for 
example,  in  1729  new  cases  treated  in  1909,  879  were  males 
and  850  were  females. 

The  age  of  the  patients  is  of  interest  as  bearing  on  the  ques- 
tion of  prognosis :  426  were  between  ten  and  twenty  years  of 
age,  and  780  were  less  than  thirty. 

Hospital  statistics  cannot  adequately  represent  the  subject, 
for,  as  a  rule,  it  is  because  of  disability  and  pain  that  these 
patients  apply  for  treatment.  In  the  larger  proportion  of  the 
cases  recorded  muscular  spasm  and  rigidity  were  present,  in 
234  instances  to  such  a  degree  that  forcible  overcorrection  was 
advised — an  operation  rarely  necessary  in  j)i'ivate  practice. 

It  is  in  childhood  that  the  prevention  of  subsequent  weakness 
and  deformity  is  of  the  first  importance,  yet  but  98  children  of 
ten  years  of  age  or  less  are  recorded,  and  many  of  these  were 
brought,  not  for  weakness  or  deformity,  but  for  treatment  of  the 
symptomatic  in-toeing. 

Symptoms. — As  has  been  stated,  the  sjTiiptoms  of  the  weak 
foot,  although  similar  in  type,  vary  in  severity  according  to  the 
local  condition  and  the  disturbance  of  function,  the  work  to  be 
performed,  and  the  susceptibility  of  the  individual.  The  earliest 
symptom  is  usually  a  sensation  of  weakness ;  the  patient  begins 
to  recognize  as  familiar  a  feeling  of  discomfort,  of  tire  and 
strain  about  the  inner  side  of  the  foot  and  ankle;  sometimes 
after  long  standing  a  dull  ache  in  the  calf  of  the  leg  or  pain  at 
the  knee,  hip,  or  in  the  lumbar  region,  symptoms  more  common 
in  women  than  in  men ;  or  after  overexertion  a  momentary  sharp 
pain  radiating  from  the  point  of  weakness;  thus  the  patient 
often  dates  the  history  of  his  trouble  from  a  long  walk  or  other 
form  of  overwork.  After  a  time  the  patient  may  become  aware 
that  he  is  accommodating  his  habits  to  his  feet;  he  rides  when 
he  once  walked;  he  sits  when  he  once  stood;  he  no  longer  runs 
up  or  down  stairs  or  springs  off  the  street-car.  His  feet  have 
lost  their  spring,  as  he  expresses  it,  which  means  that  the  foot 


716  OETHOPEDIC   SUEGEBY. 

is  uo  longer  supported  and  controlled  by  miiscnlar  activity  and 
is  no  longer  used  as  a  lever.  Xot  infrequently  early  symptoms 
are  pain  and  sensitiveness  at  the  centre  of  the  heel,  explained  in 
part  by  the  jarring  heel  vralk  which  is  always  assumed  -when  the 
foot  is  weak,  and  in  part  by  the  strain  upon  the  attachments  of 
the  deep  plantar  ligaments.  The  patient  may  complain  that  he 
cannot  buy  comfortable  shoes ;  the  reason  is  that  the  weak  foot 
under  use  is  changed  in  shape,  so  that  the  shoe  that  was  com- 
fortable in  the  morning  compresses  the  foot  painfully  at  night ; 
thus  increasing  discomfort  from  corns,  bunions,  enlarged  great 
toe-joints,  and  deformities  of  the  toes  is  experienced.  Coldness 
and  numbness,  congestion  and  increased  perspiration,  caused  by 
the  impaired  circulation  and  weakness,  are  common  symptoms 
in  this  class  of  cases.  Actual  pain  is,  as  a  rule,  felt  only  when 
the  foot  is  in  use;  it  ceases  under  temporary  rest  or  relief  from 
disproportionate  work,  and  it  is  this  remittance  of  symptoms, 
together  with  the  fact  that  the  discomfort  is  usually  more 
marked  in  damp  weather,  that  leads  so  often  to  the  mistaken 
diagTiosis  of  rheumatism.  ' 

The  foot  is  weak  and  vulnerable ;  the  patient  now  recognizes 
that  he  has  what  he  speaks  of  as  a  weak  ankle,  or  sprain,  or  gout, 
or  rheumatism,  but  if  he  has  accommodated  himself  to  the  weak- 
ness but  little  discomfort  is  experienced.  In  many  instances 
such  relief  or  accommodation  is  impossible,  and  it  is,  therefore, 
among  the  working  class  that  one  oftener  sees  rapid  development 
of  the  disability  and  deformity.  The  range  of  motion  becomes 
more  and  more  restricted;  the  habitual  attitude,  at  first  exag- 
gerated to  deformity  only  under  the  influence  of  the  weight  of 
the  body,  remains  as  a  persistent  displacement.  The  weak  and 
dislocated  foot  is  subjected  to  constant  injury,  to  what  may 
be  likened  to  a  succession  of  slight  sprains,  so  that  local  con- 
gestion, sensitiveness,  and  swelling  may  appear,  together  with 
muscular  spasm,  rigidity,  and  pain  on  passive  motion.  Be- 
cause of  this  stiffness  of  the  foot,  which  cannot  accommodate 
itself  to  inequalities  of  the  surface,  the  patient  dreads  to  cross  a 
rough  pavement,  for  every  misstep  causes  discomfort. 

Another  symj^tom,  the  discomfort  felt  in  changing  from  a 
position  of  rest  to  activity,  which  is  usually  present  in  slight 
degree  at  every  stage,  now  becomes  more  prominent.  The 
patient,  after  sitting  or  on  rising  in  the  morning,  is  unable  to 
walk,  but  staggers  or  limps  for  several  minutes,  a  symptom  ex- 
plained by  the  fact  that  when  the  foot  is  at  rest  there  is  a  certain 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         717 

relaxation  of  the  tension  that  has  become  habitual.  The  local 
sensitiveness  and  muscular  spasm  are  increased  by  use,  so  that 
the  patient  may  have  difficulty  in  removing  the  shoe  at  night, 
and  the  symptoms  relieved  by  the  rest  of  Sunday  become  pro- 
gressively worse  during  the  week.  The  pain  and  discomfort  are 
more  general  in  character,  and  are  often  referred  to  the  dorsum 
of  the  foot,  representing  muscular  tension  and  contraction  and  to 
the  ankle  where  the  external  malleolus  is  grinding  out  a  facet 
in  the  projecting  os  calcis.  The  patient  may  now  complain  of 
discomfort  in  the  feet  and  cramps  in  the  legs,  even  when  in  bed, 
and  the  weakness,  awkwardness,  and  even  mental  depression 
may  be  so  noticeable  that  the  case  is  sometimes  mistaken  for 
serious  disease  of  the  nervous  system. 

The  appearance  of  such  a  foot  has  already  been  described,  and 
the  effect  of  the  deformity  on  its  functions  should  be  evident. 
The  gait  is  slouchy,  what  has  been  spoken  of  as  the  pedestal 
walk;  the  feet  are  simply  pushed  by  one  another,  in  the  atti- 
tude of  eversion,  the  knees  are  slightly  flexed,  and  the  weight 
is  borne  entirely  upon  the  posterior  segment  of  the  foot.  The 
muscles  have  atrophied,  the  foot  is  cold  and  congested  from 
its  continued  inactivity,  and  it  is  usually  bathed  in  perspiration. 
A  certain  range  of  motion  remains  at  the  ankle-joint,  but  adduc- 
tion is  absolutely  restricted  by  the  shortened  and  spasmodically 
contracted  muscles  on  the  outer  and  upper  surface.  This  type 
represents,  of  course,  only  the  severe  variety  that  is  more  likely 
to  be  seen  in  hospital  than  in  private  practice;  and  it  would 
seem,  were  it  not  for  the  evidence  to  the  contrary  with  the  his- 
tories of  the  patients  present,  that  the  nature  of  the  trouble  must 
be  recognized  at  a  glance.  But  in  the  milder  and  earlier  cases 
the  diagnosis  is  not  always  so  easily  made. 

Diagnosis. — In  all  cases  of  suspected  weakness  of  the  foot  a 
thorough  and  orderly  examination  should  be  made,  not  only  of 
its  appearance,  but  also  of  its  functional  ability.  Such  an  ex- 
amination is  not  merely  for  the  purpose  of  diagnosis,  but  in 
order  that  the  degree  and  character  of  the  temporary  or  perma- 
nent changes  in  structure  and  function  may  be  properly  esti- 
mated. 

Attitudes. — One  begins  the  examination  by  noting  the  manner 
of  standing  and  walking.  The  heel  walk,  the  exaggerated  turn- 
ing out  of  the  feet,  the  slouchy  gait  in  which  the  leg  is  never 
completely  extended,  in  which  the  power  of  the  calf  muscle  is 
not  applied,  and  in  which  the  essential  postures  of  the  foot  are 


718  OBTEOPEDIC  SUEGEBY. 

disused,  are  all  elements  of  weakness  that  should  be  corrected 
whether  they  cause  symptoms  or  not. 

Distribution  of  Weight  and  Strain. — The   distribution  of  the 
weight  of  the  body  and  the  habitual  use  of  the  foot  are  often 

Fig.  471. 


The  ordinary  type  of  weak  foot  in  a  child.     The  attitude  of  abduction  causes  the 
apparent  flat-foot.      (See  Fig.  472. j 

made  evident  by  examining  the  worn  shoe.  If  it  is  bulged  in- 
ward at  the  arch  or  worn  away  on  the  inner  side  of  the  sole  it 
shoAvs  weakness  (Fig.  475).  The  same  observations  are  then 
made  on  the  bare  feet,  particular  attention  being  paid  to  the  line 
of  strain  or  leverage ;  thus  a  line  drawn  down  the  crest  of  the 
tibia  from  the  centre  of  the  patella,  continued  over  the  foot, 
should  meet  the  interval  between  the  second  and  third  toes ;  if 
it  falls  over  or  inside  the  great  toe.  it  shows  that  the  foot  is 
working  at  a  disadvantage  (Fig.  469). 

Contour. — The  contour  of  the  foot  should  then  be  examined* 
its  internal  border  should  curve  slightly  outward,  so  that  if  the 
feet  are  placed  side  by  side  with  the  toes  and  heels  in  apposition 
a  slight  interval  remains  between  them;  if  this  slight  concavity 


DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT. 


719 


is  replaced  by  a  noticeable  convexity  when  weight  is  borne  the 
foot  is  weak  (Fig.  470).  This  change  in  contour  is  the  earliest 
and  sometimes  the  only  evidence  of  deformity.  The  arch  of  the 
foot  properly  protected  by  the  muscles  and  by  a  proper  attitude, 
sinks  but  little  under  weight;  there  is  a  slight  elasticity  only, 
as  the  strain  is  thrown  more  to  the  inner  side  of  the  median  line, 
and  if  the  depression  is  marked  it  shows  weakness. 

Bearing  Surface. — The  exact  amount  of  bearing  surface  may 
be  show^n  by  an  imprint  upon  carbon  paper  or  by  smearing  the 

Fig.  472. 


Voluntary    correction  of  the   deformity,   illustrating  particularly   the   restoration 
of  the  arch.      (See  Fig.  471.) 


sole  with  vaseline ;  then,  as  the  patient  stands  upon  a  sheet  of 
white  paper,  the  outline  of  the  foot  should  be  traced  so  that  the 
relative  size  of  the  imprint  to  that  of  the  foot  may  be  shown 
and  compared  with  the  normal  standard  (Fig.  477). 

Of  all  the  tests  this,  so  often  used  to  demonstrate  the  height 
of  the  arch  and  thus  to  confirm  a  diagnosis  of  flat-foot,  is  of  the 
least  importance. 

The  Range  of  Motion. — The  balance  of  the  foot,  -as  shown  by 
the  range  of  motion,  is  next  to  be  tested,  for  its  limitation  is  one 


720  OETHOPEDIC   SUEGEEY. 

of  the  earliest  signs  of  improper  attitudes  and  of  weakness. 
This  range  of  motion  varies  somewhat  within  normal  limits ;  it 
is  usually  greater  in  childhood  than  in  adult  life,  greater  in  the 
slender  than  in  the  massive  foot,  and  greater  in  the  foot  used 
properly  than  in  one  that  is  not.  The  first  test  is'  applied  to 
simple  dorsal  and  plantar  flexion ;  the  leg  must  be  fully  extended 
at  the  knee ;  the  line  of  strain  must  be  in  its  normal  relation,  so 
that  the  foot  may  be  neither  adducted  nor  abducted,  and  the  ob- 
servation must  be  made  on  its  outer  border. 

In  this  position  the  patient  should  be  able  to  flex  the  foot  from 
10  to  20  degrees  less  than  the  right  angle,  and  to  extend  it  from 
40  to  50  degrees  beyond  the  right  angle,  the  range  of  motion 
being  from  50  to  60  degrees  (Tigs.  449  and  450). 

By  far  the  most  important  test  is  that  of  the  power  of  adduc- 
tion or  inversion  of  the  foot,  the  test  of  the  mediotarsal  and  sub- 
astragaloid  joints,  a  motion  in  which  the  os  caleis  is  drawn  for- 
ward and  inward  under  the  astragalus,  while  the  forefoot  is 
flexed  about  its  head.  With  the  leg  extended  and  the  patella  in 
the  median  line  the  foot  is  turned  inward  as  far  as  possible ;  the 
elevation  of  its  inner  border  or  inversion  and  the  turning  in  of 
the  heel  are  well  illustrated  in  Fig.  451;  the  actual  range  of  ad- 
duction is  somewhat  difficult  to  measure,  but  it  is  about  30  de- 
grees. Even  the  mild  and  early  cases  of  weak  foot  usually  show 
some  limitation  of  this  most  important  motion,  and  in  many 
instances  it  is  completely  lost,  the  patient  turning  the  entire 
limb  in  the  efi^ort  to  adduct  the  foot.  The  less  important  motion 
of  abduction  may  be  tested  also  (Fig.  452)  ;  its  range  is  about 
half  that  of  adduction,  so,  also,  the  range  of  inversion  of  the 
sole  is  nearly  twice  as  great  as  that  of  eversion  of  the  sole. 
In  other  words,  the  internal  border  of  the  foot  can  be  raised 
twice  as  far  from  the  floor  as  can  the  external  border.  The 
range  of  passive  motion  is  then  tested  by  pushing  the  foot  in  all 
directions.  The  range  of  dorsal  flexion  is  from  five  to  ten 
degrees  beyond  that  of  voluntary  motion,  while  passive  exten- 
sion, so  far  as  it  applies  to  the  ankle-joint,  is  about  the  same 
as  the  voluntary,  although  the  forefoot  may  be  still  farther  bent 
downward  at  the  mediotarsal  joint.  The  limit  of  passive  ad- 
duction is  considerably  beyond  that  of  voluntary  inversion.^ 

'■  As  adduction  and  inversion  and  abduction  and  eversion  are  always  com- 
bined, one  term  is  used  to  signify  the  movement  inward  or  outward;  thus, 
inversion  means  adduction ;  abduction  implies  eversion.  A  fixed  attitude  of 
adduction  and  inversion  is  called  varus;  a  fixed  attitude  of  abduction  and 
eversion  is  called  valgus.     Varus  and  valgus  signify,   therefore,   deformity. 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         721 

Passive  motion  serves  several  purposes;  contrasted  with  the 
range  of  voluntary  motion  it  shows  the  habitual  use  of  the  foot, 
since  the  motion  least  used  is  most  limited.  It  also  makes  evi- 
dent the  slight  restriction  of  motion  and  the  presence  of  local 
sensitiveness,  which,  even  in  early  cases,  are  usually  present. 
Thus,  if  pressure  is  made  just  in  front  of  and  below  the  internal 
malleolus,  at  the  astragalonavicular  junction,  and  if  at  the  same 
time  the  foot  is  forcibly  adducted,  the  patient  will  complain  of 
pain  at  the  point  of  pressure  and  of  a  feeling  of  constriction  and 
tension  about  the  dorsum  of  the  foot  before  the  normal  limit  of 
motion  is  reached.  When  the  foot  is  dorsiflexed  the  plantar 
fascia  is  put  upon  the  stretch,  and  its  condition  may  be  noted, 
for  a  contracted  and  sensitive  plantar  fascia  may  cause  sufficient 
discomfort  to  induce  improper  attitudes  and  thus  it  may  predis- 
pose to  further  disability. 

Varieties, — This  method  of  examination  will  demonstrate  the 
disability,  and  the  secondary  changes  in  the  mechanism,  which 
must  be  overcome  before  a  cure  can  be  accomplished.  By  it  one 
may  recognize  several  grades  of  weak  foot : 

1.  The  normal  foot  improperly  used,  as  shown  by  the  manner 
of  standing  and  walking  (Fig.  447). 

2.  The  foot  which  because  of  laxity  of  ligaments  or  insuffi- 
cient muscular  support  is  forced  by  the  weight  of  the  body  into 
an  attitude  of  deformity ;  that  is,  in  which  the  foot  under  weight 
falls  into  an  abnormal  attitude  of  abduction  in  its  relation  to  the 
leg  as  evidenced  by  the  inward  projection  of  its  inner  border  and 
by  the  overhanging  internal  malleolus.  As  a  rule,  there  is  suffi- 
cient laxity  of  ligaments  to  permit  depression  of  the  arch,  as 
shown  by  the  imprint,  but  in  other  instances,  although  the  arch 
seems  lower  because  of  the  characteristic  attitude  of  abduction, 
in  which  the  leg,  as  it  were,  overhangs  the  foot,  yet  the  imprint 
shows  that  there  is  no  increase  in  the  area  of  bearing  surface. 
Indeed,  if  the  eversion  is  sufficient  to  raise  the  outer  border  of 
the  foot,  this  may  be  even  smaller  than  normal ;  thus,  an  indi- 
vidual may  suffer  from  so-called  flat-foot  whose  arch  is  actually 
exaggerated  (Fig.  470). 

3.  The  weak  foot,  which  shows  typical  deformity  under  use 

Thus  the  term  valgus,  although  it  may  be  properly  applied  to  designate  the 
deformity  of  weak  foot,  is  usually  reserved  for  the  more  extreme  and 
persistent  distortion  of  talipes.  The  terms  supination  and  pronation  are 
sometimes  used  for  inversion  and  eversion  and  the  term  pronated  foot  to 
designate  the  weak  or  flat-foot.  As  pronation  signifies  an  attitude  of 
activity  it  can  not  as  correctly  describe  a  deformity  which  is  essentially 
one  of  inactivity  as  either  eversion  or  abduction. 

46 


722  OBTHOPEDIC  SUBGEBY. 

and  in  which  the  range  of  voluntary  motion  is  somewhat  limited, 
particularly  in  the  direction  of  plantar  flexion  and  adduction. 
Forced  motion  causes  discomfort  and  pain,  indicating  certain 
accommodative  changes  in  structure,  which  are  not  apparent 
when  the  foot  is  not  in  use  (Fig.  471). 

4.  The  foot  which  presents  typical  and  persistent  deformity, 
whether  it  is  in  use  or  not,  and  in  which  the  range  of  both 
voluntary  and  passive  motion  is  much  restricted.  In  all  of  these 
varieties  the  improper  functional  use  of  the  foot,  particularly  the 
loss  of  active  leverage,  is  very  evident  when  the  patient  walks 
(Fig.  475). 

Limitation  of  Motion  and  Muscular  Spasm, — Limitation  of  mo- 
tion is  caused  by  the  changes  in  structure  in  accommodation  to 
functional  use.  These  are  first  evident  in  the  muscles  and  liga- 
ments, and,  finally,  in  the  articular  surfaces  of  the  bones. 
Added  to  this  underlying  limitation  of  motion  there  is  usually 
a  certain  degree  of  muscular  spasm,  which  varies  in  grade  with 
the  local  congestion,  irritation,  and  inflammation  of  the  joints 
and  tissues.  In  the  quiescent  flat-foot  it  may  be  absent,  but  on 
renewed  injury  or  overwork  of  the  weak  structure  it  again  ap- 
pears. It  depends  also  upon  the  irritable  condition  of  the  over- 
worked and  contracted  abductor  muscles,  practically  the  only 
group  which  retains  functional  power ;  thus  the  spasm,  as  has 
been  stated  in  describing  the  severe  and  painful  type  of  weak 
foot,  is  greater  after  the  day's  use  and  relaxes  somewhat  during 
the  night.  The  degree  of  muscular  spasm  and  rigidity  corre- 
sponds with  the  intensity  of  the  symptoms,  but  by  no  means 
with  the  depression  of  the  arch  or  with  the  duration  of  the  de- 
formity. 

Extreme  Types  of  Weak  Foot. — 1.  Persistent  Adduction. — In 
one  type  of  deformity  the  foot  is  twisted  outward  and  upward. 
It  may  be  everted  to  such  an  extent  that  practically  the  weight 
is  borne  upon  the  heel  and  the  ball  of  the  great  toe.  The  entire 
foot  is  simply  held  in  an  attitude  of  extreme  abduction  and 
dorsal  flexion  by  the  spasm  and  contraction  of  the  flexors  and 
abductors,  so  that  the  leg  must  be  bent  at  the  knee  and  inclined 
forward  to  bring  the  sole  to  the  ground.  Such  extreme  cases  are 
uncommon.  They  are  often  the  direct  result  of  injury,  so-called 
chronic  sprain.  Less  extreme  examples  of  this  class  are  very 
common.  The  foot  is  simply  turned  to  one  side  (valgus)  and  the 
arch  appears  to  be  depressed  because  of  the  attitude,  whereas  it 
may  be  in  reality  exaggerated  in  depth. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


723 


2.  Pes  Planus, — As  has  been  stated  already,  and  as  is  well- 
known,  there  is  a  type  of  painless  flat-foot  sometimes  called  pes 
planus,  in  which  the  flatness  of  the  foot  is  more  noticeable  than 
the  other  components  of  the  deformity  that  have  been  described. 
This  is  probably  the  result  of  inherited  laxity  of  ligaments  or  of 
rhachitis  or  other  form  of  acquired  weakness  in  early  life,  so 
that  a  normal  arch  was  never  present.  Such  a  foot  controlled  by 
normal  muscles  may  be  strong  and  efficient,  but  it  is,  neverthe- 
less, deformed,  and  it  is  doubtful  if  its  possessor  ever  could  at- 
tain the  grace  and  elasticity  of  gait  possible  under  normal  con- 

FiG.  473. 


Weak  feet  and  slight  knock-knee. 


ditions.  It  is  said,  also,  that  a  low  arch  is  normal  in  certain 
races,  for  example,  the  negro,  but  the  American  negro  is  cer- 
tainly not  exempt  from  the  pain  and  disability  incidental  to 
the  broken-down  foot. 

It  is  evident,  of  course,  that  the  breaking  down  of  a  properly 
shaped  foot,  supported  by  normal  ligaments,  will  be  attended 
by  greater  pain  and  greater  disability  than  of  one  in  which  the 
arch  was  originally  low  and  of  which  the  ligaments  were  weak,, 
because  it  is  during  the  progression  of  the  deformity  and  par- 
ticularly in  its  early  stages  that  such  symptoms  are  most  promi- 


724  OBTROPEDIC  SUBGEBY.  , 

nent.  When  the  bones  of  the  arch  rest  npon  the  ground  or  when 
final  stability  has  become  assured,  pain  may  cease,  and  perma- 
nent accommodation  to  the  new  conditions  may  increase  the 
ability  of  the  deformed  member.  Such  an  outcome  might  be 
quickly  accomplished  in  the  foot  originally  flat,  while  in  the 
other  instance  the  symptoms,  although  remitting  from  time  to 
time,  might  continue  indefinitely. 

The  abducted  foot,  in  which  there  is  no  depression  of  the  arch, 
and  the  simple  flat-foot,  in  which  the  element  of  abduction  is 
less  prominent,  represent  the  two  extremes  of  weak  foot.  In 
the  majority  of  cases  the  two  are  combined  in  varying  degree. 

One  may  recognize,  then,  three  types  of  weak  foot  which  may 
be  classified  according  to  the  more  noticeable  deformity  as 

1.  Valgus,  or  abduction. 

2.  Valgo-planus,  or  abduction  and  depression. 

3.  Plano-valgTis,  or  depression  and  abduction. 

This  distinction  is  of  some  importance  from  the  standpoint  of 
prognosis,  at  least  in  the  adolescent  and  adult  cases,  as  the  pros- 
pect of  anatomical  cure  corresponds  to  the  order  of  classification. 

Weak  Foot  in  Childhood. — There  can  be  no  doubt  that  in 
many  instances  the  origin  of  the  weak  foot  may  be  traced  to  early 
childhood.  Certainly,  deformities  and  improper  attitudes  are 
very  common  at  this  period,  and  it  is  much  more  likely  that  they 
are  ingrown  than  outgTown.  Actual  pain  from  the  weak  foot  is 
unusual  at  this  age.  The  child  may  complain  of  fatigue  and 
may  be  weak  and  awkward,  but  it  is  usually  because  of  the  very 
evident  deformity  rather  than  because  of  symptoms  that  advice 
is  asked.  In  these  cases,  as  in  every  case,  the  habitual  attitudes 
and  use  of  the  feet  are  of  the  first  importance. 

Out-toeing  and  In-toeing  as  Symptoms. — One  of  the  most  com- 
mon of  the  improper  postures  of  civilization  is  that  of  exag- 
gerated outward  rotation  of  the  limbs  (turning  outward  of  the 
feet),  which  is  not  only  an  ungTaceful  attitude,  but  a  direct 
cause  of  weakness  as  well.  The  opposite  attitude  of  inward  rota- 
tion, the  so-called  "  pigeon-toed "  walk,  is  most  offensive  to 
relatives  and  friends,  and  it  is  for  correction  of  the  attitude  that 
the  child  may  be  brought  for  treatment.  The  attitude  is,  in 
many  instances,  a  sign  of  the  weak  foot,  for  on  examination 
the  bulging  on  the  inner  side,  the  inward  rotation  of  the  leg  in 
its  relation  to  the  foot,  and  the  depressed  arch  show  very  plainly 
that  it  is  the  foot  and  not  the  attitude  that  requires  treatment ; 
in  fact,  the  attitude. is,  in  this  class  of  cases,  really  a  safeguard 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         725 

against  increasing  deformity,  which  will  correct  itself  when  its 
cause  is  removed.-^  Particular  emphasis  is  laid  upon  this  point, 
which  is  very  generally  overlooked,  because  the  routine  treat- 
ment of  the  "  pigeon-toes  "  in  these  cases  might  be  the  cause  of 
direct  harm. 

Weak  Ankles. — "'  Weak  ankle  "  is  a  term  popularly  applied  to 
the  weak  foot  of  childhood,  in  which  the  foot  is  in  a  position  of 
valgTis  when  in  use,  so  that  the  sole  of  the  shoe  is  worn  away  on 
its  inner  side.  Weak  ankles  are  very  common  in  young  children 
and  are  often  one  of  the  results  of  general  weakness  due  to  defec- 
tive assimilation.  At  this  age  the  foot  is,  in  addition,  usually 
flat  (Fig.  473),  but  in  the  valgus  or  weak  ankle  of  later  years 
the  arch  is  often  found  to  be  exaggerated  when  the  foot  is  placed 
in  proper  relation  to  the  leg. 

Outgrown  Joints, — In  older  children  '"'■  outgrown  "  joints  often 
attract  the  mother's  attention ;  the  internal  malleoli  appear 
prominent  because  of  the  position  of  valgus,  or  because  of  the 
turning  out  of  the  feet  the  malleoli  may  strike  against  one 
another,  "  interfere,"  and  thus  there  may  be  an  actual  hyper- 
trophy of  the  tissues  over  the  projecting  bones  from  local  irri- 
tation. 

Another  type  is  the  long,  slender  abducted  foot,  in  which  the 
inward  bulging  at  the  mediotarsal  joint  is  indicated  by  the  point 
of  wear  in  the  leather  of  the  shoe  (Fig.  470). 

In  the  weak  foot  of  childhood,  although  restriction  of  volun- 
tary and  passive  motion  may  be  present,  there  are,  as  a  rule,  but 
little  local  sensitiveness  and  muscular  spasm,  and,  as  has  been 
said,  but  little  actual  pain,  for  the  reason  that  the  weak  foot  in 
childhood  is  not  subjected  to  the  strain  of  constant  occupation 
or  to  the  burden  of  an  overweighted  body.  There  is  also  another 
important  difference:  the  foot  of  the  adult  is  obliged  to  bear 
greater  strain  than  any  other  part,  and  although  normal  in 
structure  it  may  be  overworked,  so  that  in  many  instances  the 
weakness  of  the  foot  is  the  only  disability.  But  in  childhood, 
when  such  exciting  causes  are  absent,  a  weak  foot  is  very  often 
a  local  indication  of  general  weakness  and  loss  of  tone. 

Irregular  Forms  of  Weak  Feet, — Occasionally  the  apex  of  the 
inward  bulging  and  deformity  is  not  at  the  mediotarsal  joint, 
but  anterior  to  it  in  the  cuneiform  region.     In  such  cases  the 

^  Inward  rotation  of  the  limb,  an  attitude  controlled  by  the  muscles  at 
the  hip,  and  inversion  of  the  foot  are  usually  confounded.  Inward  rotation 
of  the  limb  (pigeon-toe)  and  eversion  of  the  foot  (weak  foot)  are  often 
combined  in  childhood. 


726 


OBTHOPEDIC  SUBGEBT. 


internal  cuneiform  bone  maj  be  enlarged  and  sensitive  to 
pressure. 

Another  form  is  the  combination  of  a  plantar  flexed  toe  with  a 
depressed  arch  (Fig.  476).  Extreme  deformity  of  this  class  is 
usually  congenital.  A  milder  type  is  not  uncommon.  (See 
Hallux  Rigidus.)  A  third  variety  is  eversion  at  the  mediotarsal 
region  combined  with  marked  adduction  of  the  metatarsus. 
This  is  a  congenital  deformity. 

Weak  Feet  and  Deformity  of  the  Legs.- — In  childhood  weak  feet 
are  often  seen  in  combination  with  slight  knock-knee  (Fig. 
473),  while  in  later  life  knock-knee  usually  induces  in  compen- 


FiG.  474. 


Fig.  475. 


Congenital  flat-foot.  Rigid  deform- 
ity of  an  extreme  type,  illustrating  the 
component  abduction  and  obliteration 
of  the  arch. 


Flat-foot    illustrating    extreme    deformity    in 
childhood. 


sation  the  opposite  attitude  of  adduction.  (See  Knock-knee.) 
Bow-leg  in  childhood  is  usually  accompanied  by  slight  adduc- 
tion of  the  feet,  but  later  there  is  usually  a  certain  degree  of 
compensatory  valgus,  although  it  does  not,  as  a  rule,  cause  dis- 
comfort. 

G-eneral  Weakness. — The  direct  effects  of  the  weak  and  pain- 
ful foot  have  been  described  in  detail.  It  must  be  borne  in  mind 
that  the  feet  support  the  body,  and  that  an  insecure  support 
affects  the  entire  mechanism.     General  functional  weakness  and 


DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT. 


727 


awkwardness,  the  flat  chest,  round  shoulders,  or  other  curvatures 
of  the  spine,  are  often  observed  as  accompaniments  or  effects  of 
weak  feet.  Thus,  as  a  rule,  the  systematic  treatment  of  any  form 
of  postural  weakness  must  include  the  treatment  of  the  feet  as 
well. 

Review. — The  disability  and  deformity  of  the  weak  or  so- 
called  flat-foot  are  caused  by  disproportion  between  the  strength 
of  the  foot  and  the  weight  and  strain  to  which  it  is  subjected. 

The  foot  may  be  weakened  by  injury  or  disease ;  it  may  be 
overburdened  by  the  body  weight,  or  overstrained  by  laborious 

Fig.  476. 


Hammer-toe  flut-fuot. 


occupation,  or  the  broken-down  foot  may  be  simply  one  indica- 
tion of  general  bodily  weakness.  It  is  unnecessary  to  enumerate 
all  the  various  factors  that  singly  or  combined  lead  to  this  dis- 
ability. It  may  be  stated,  however,  that  in  adult  life  the  weak 
foot  is  in  many  or  most  instances  the  only  disability  that  de- 
mands treatment.  Its  most  constant  predisposing  causes  are  the 
.direct  injury  caused  by  improper  shoes  and  the  mechanical  dis- 
advantages to  which  it  is  subjected  by  the  assumption  of  im- 
proper attitudes. 

All  weak  or  flat  feet  are  mechanically  weak,  but  all  weak  feet 
are  by  no  means  painful  feet.  Pain,  the  symptom  of  over-strain 
or  injury,  bears  no  definite  relation  to  the  degree  of  deformity. 

In  certain  instances  persistent  abduction  of  the  foot  may  be 
accompanied  by  exaggeration  of  the  arch ;  in  others,  the  flatten- 
ing of  the  arch  may  be  the  most  noticeable  deformity,  but  in 


728  ■  OBTHOPEDIC  SUFiGEBY. 

most  cases  the  two  are  combiued  in  varying  degree.  And  as 
each  deformity  is  an  evidence  of  weakness,  it  seems  hardly  nec- 
essary to  make  a  radical  distinction  between  the  two,  except  as 
regards  prognosis.  For  the  abducted  foot  in  which  the  arch 
is  intact  is  almost  always  an  acquired  deformity  of  short  dura- 
tion, whereas  in  the  case  of  the  foot  in  which  the  arch  is  obliter- 
ated the  deformity  usually  dates  from  early  childhood,  and  it  is, 
therefore,  less  amenable  to  treatment  as  far  as  perfect  cure  is 
concerned. 

Treatment. — The  principles  of  the  treatment  which  leads  to 
the  permanent  cure  of  the  weak  and  deformed  foot  are  very 
simple,  but  the  application  varies  somewhat  according  to  the 
gTade  and  duration  of  the  deformity.  The  object  of  treatment 
is  to  so  change  the  weak  foot  that  it  may  conform  not  only  in 
contour  but  in  habitual  attitudes  and  in  j)ower  of  voluntary 
motion  to  the  normal  foot,  l^ecause  complete  cure  is  impossible 
unless  normal  function  is  regained.  The  first  step  must  be, 
therefore,  to  make  jDassive  motion  free  and  painless  to  the  normal 
limit.  In  other  words,  the  obstructions  to  the  motion  of  the 
mechanism  must  be  removed  before  the  power  can  be  properly 
applied;  for  the  increase  of  muscular  strength  and  ability,  on 
which  ultimate  cure  depends,  is  not  possible  while  motion  is 
restrained  by  deformity  or  by  pain  or  by  adhesions  or  contrac- 
tions. 

The  weak  foot,  because  of  inefficient  ligaments  and  muscles 
unable  to  hold  itself  in  j)roper  position,  must  be  supported  until 
regenerative  changes  have  taken  place  in  its  structure.  Such 
support  is  necessary  to  retain  the  joints  in  normal  position,  and 
to  hold  the  weight  in  proper  relation  to  the  foot,  otherwise 
normal  function  is  impossible.  When  these  essentials  are  pro- 
vided the  patient  may  cure  himseK  by  the  proper  functional  use 
of  the  foot  and  by  the  avoidance  of  attitudes  that  place  it  at  a 
disadvantage. 

It  may  be  well  to  describe,  first,  the  treatment  that  must  be 
applied  to  all  classes  of  weak  foot  in  which  a  cure  is  to  be  at- 
tempted and  which  by  itself  is  sufficient  in  the  milder  types, 
before  calling  attention  to  the  modifications  that  may  be  neces- 
sary in  more  advanced  cases. 

"'  The  Shoe, — In  all  cases  it  will  be  necessary  to  provide  the 
patient  with  a  proper  shoe,  for  the  shoe  is  usually  the  direct 
cause  of  the  minor  deformities,  and  indirectly,  in  many  in- 
stances, of  more  serious  disability.     Indeed,  most  of  the  de- 


DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT. 


729 


Fig.  477. 


formities  and  disabilities  of  the  foot  are  incidental  to  civiliza- 
tion, and  are,  therefore,  confined  to  the  shoe-wearfng  people. 
The  direct  effect  of  the  ordinary  shoe  is  to  lessen  the  area  and 
the  adjustability  of  the  fulcrum  by  cramping  the  toes.  Indi- 
rectly it  causes  deformities— corns,  bunions,  and  the  like — 
which  serve  to  make  active  move- 
ment or  leverage  painful,  so  that  it 
is  replaced  by  the  passive  attitude. 
The  proper  shoe  should  contain 
sufficient  space  for  the  independent 
movements  of  the  toes.  This  motion 
is  illustrated  in  the  w^alk  of  the  bare- 
foot child.  As  the  v^^eight  falls  on 
the  foot  the  toes  spread,  and  as  the 
body  is  raised  on  the  foot  they  con- 
tract. The  important  leverage  ac- 
tion of  the  great  toe  and  the  support 
afforded  by  it  to  the  arch  of  the 
foot  have  been  mentioned  already. 
The  shape  of  the  sole  should  corre- 
spond to  the  shape  of  the  foot  and 
the  heel  should  be  broad  and  low. 
It  will  be  noted  that  the  front  of  the 
sole  of  the  shoe  in  Fig.  477  appears 
to  be  twisted  inward.  Such  a  shoe 
aids  in  preventing  abduction,  and  it 
is,  therefore,  an  important  adjunct 
,to  the  brace  in  restraining  deformity. 
j7  Raising  the  Inner  Border  of  the 
Shoe. — A  simple  expedient  in  the 
treatment  of  the  weak  foot  and  an 
aid  in  balancing  it  properly  is  to 
make  the  inner  border  of  the  sole 
and  heel  of  the  shoe  slightly  thicker 


in  order  to  throw  the  weight  toward 


The  proper  relation  of  the 
sole  to  the  shape  of  the  foot : 
Aj,  outline  of  sole ;  B,  outline  of 
foot ;  C,  imprint  of  foot. 


the  outer  side  of  the  foot.     This  is 

of  special  importance  in  the  treatment  of  the  slighter  degrees  of 
what  is  known  as  weak  ankle,  and  it  is  always  of  service  in  the 
treatment  of  any  grade  of  weak  foot. 

Attitudes.. — The  patient's  attention  is  then  called  to  the  sig- 
nificance of  the  bulging  on  the  inner  side  of  the  foot  (Fig.  470) 
and  how  this  may  be  prevented  by  throwing  the  weight  on  the 
outer  side  of  the  foot  (Fig,  471)  and  by  holding  the  feet  par- 


730  OBTHOPEDW  8UBGEBY. 

allel  with  one  another  in  walking  and  by  crossing  the  feet  in  the 
sitting  posture  (Fig.  465).  The  importance  of  leverage  is 
shown  him,  that  he  must  try  to  press  down  the  sole  of  the  shoe 
with  his  toes,  particularly  with  the  great  toe,  and  employ  the 
active  lift  of  the  calf  muscles  by  fully  extending  the  leg  and 
raising  the  body  on  the  foot  from  time  to  time  (Fig.  447). 
Finally,  in  standing,  he  must  avoid  long  continuance  in  one  posi- 
tion, especially  the  passive  posture,  which,  even  in  the  normal 
subject,  simulates  the  attitude  and  deformity  of  weak  foot.  In 
short,  he  must  be  instructed  in  the  mechanics  of  the  foot  and 
taught  how  the  weak  foot  may  be  protected  as  well  as  strength- 
ened. 

I  Exercises. — It  is  important,  also,  to  demonstrate  to  the  patient 
the  normal  range  of  motion  of  the  foot,  motion  which,  if  restricted, 
must  be  regained  by  voluntary  and  passive  exercises.  Voluntary 
exercise  should  be  devoted  to  strengthening  the  adductors  and 
plantar  flexors;  thus  the  foot  should  be  adducted  and  inverted, 
then  dorsiflexed  in  the  attitude  of  slight  adduction  (Fig.  451) 
over  and  over  again  at  every  opportunity.  Tip-toe  exercises  are 
especially  useful ;  the  patient,  placing  the  feet  in  the  attitude  of 
moderate  inward  rotation,  raises  the  body  on  the  toes  to  the  ex- 
treme limit,  the  limbs  being  fully  extended  at  the  knees,  then 
sinking  slowly,  resting  the  weight  on  the  outer  borders  of  the 
feet,  in  the  attitude  of  marked  varus,  twenty  to  one  hundred 
times.  This  exercise  is  somewhat  difficult,  and  it  cannot  be 
carried  out  properly  if  there  is  any  limitation  of  motion  or  sen- 
sitiveness at  the  mediotarsal  joints.  The  best  of  all  exercises 
is,  however,  the  proper  walk,  in  which  the  leverage  power  of  the 
foot  is  employed  and  in  which  it  passes  through  the  proper  alter- 
nation of  postures  (Fig.  447).  Treatment  by  massage  and 
special  gymnastic  exercises  is,  of  course,  of  benefit  if  the  patient 
can  command  it,  although  by  no  means  essential  to  the  cure. 

Support. — In  many  instances  the  simple  treatment  that  has 
been  outlined  is  all  that  is  required,  but  in- the  majority  of  cases 
the  patient  is  not  able  to  prevent  deformity  voluntarily ;  conse- 
quently a  support  is  necessary  to  hold  the  foot  in  proper  posi- 
tion and  to  relieve  discomfort.  It  is  usually  necessary  in  the 
treatment  of  the  weak  foot  of  childhood  because  one  cannot  com- 
mand  the  aid  of  the  patient. 

In  selecting  a  support  for  the  weak  foot  the  nature  of  the 
deformity  should  be  borne  in  mind ;  that  the  acquired  flat-foot, 
for  example,  is  not  a  direct  breaking  down  of  the  arch,  as  is 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


731 


usually  taught,  but  a  lateral  deviation  and  sinking — a  compound 
deformity,  as  has  been  already  described  (Fig.  466).  Thus  a 
brace  to  be  efficient  must  hold  the  foot  laterally  as  well  as  sup- 
port the  arch.  But  it  must  not  prevent  the  normal  motions  of 
the  foot,  and  thus  interfere  with  the  increase  of  muscular 
strength  and  ability,  on  which  ultimate  cure  depends. 


Fig.  478. 


Fig.  479. 


The    tip-toe    exercise,    rai.siug    the    body    ou 
the  adducted  feet.     (See  Fig.  479.) 


The    tip-toe    exercise,    resting    ou    the 
outer    borders    of    the    feet.       (See    Fig. 

478.) 


The  supports  that  are  ordinarily  used  for  flat-foot  do  not  ful- 
fil the  conditions ;  the  pads,  springs,  and  plates  placed  beneath 
the  arch  are  intended  to  support  it  by  direct  pressure  without 
regard  to  the  abduction;  they  are  usually  ill-fitting,  and  are 
often  of  such  length  and  shape  as  to  splint  the  foot  and  thus  to 
restrict  its  motion.  Leg  braces  which  control  the  valgus  do  not 
often  hold  the  foot  accurately,  and  their  weight  and  unsightliness 
are  fatal  objections  to  their  use,  especially  in  the  early  cases,  in 
which  prevention  of  subsequent  deformity  is  of  such  importance. 


732 


ORTHOPEDIC   SURGEBY. 


A  brace  should  never  be  ajoplied  to  a  deformed  and  rigid  foot 
because  it  cannot  adapt  itself  to  the  support ;  the  spasm  and 
rigidity  should  be  first  relieved  by  the  preliminary  treatment, 
that  will  be  described  in  the  consideration  of  this  class  of  cases. 

The  Construction  of  the  Brace. — To  properly  construct  a  brace 
to  meet  these  conditions,  it  is  necessary  to  provide  the  mechanic 
vt'ith  a  jDlaster  cast  of  the  foot,  taken  in  the  attitude  in  which  one 
wishes  to  support  it.     Such  a  model  may  be  easily  and  quickly. 


made  in  the  following  manner 


Fig.  480. 


The  attitude  in  which  the  plaster  cast  should  be  taken.  This  attitude  is 
important,  because  in  it  the  foot  assumes  the  best  possible  contour.  If  the  sole 
is  simply  pressed  downward  into  the  plaster  cream,  the  ordinary  method  of  mak- 
ing the  model,  the  shape  will  be  found  to  be  quite  different  from  that  taken  in 
the  manner  illustrated. 


The  piaster  Cast. — Seat  the  patient  in  a  chair ;  in  front  of  him 
place  another,  preferably  a  rocking  chair,  somewhat  less  in 
height;  on  it  lay  a  thick  pad  of  cotton-batting  and  cover  it  with 
a  square  of  cotton  cloth.  Put  about  a  quart  of  cold  water  into 
a  basin  and  sprinkle  plaster-of-Paris  on  the  surface  until  it  does 
not  readily  sink  to  the  bottom ;  then  stir.  When  the  mixture  is 
of  the  consistency  of  very  thick  cream  pour  it  upon  the  cloth. 
The  patient's  knee  is  then  flexed,  and  the  outer  side  of  the  foot, 
previously  rubbed  with  talcum  powder,  is  allowed  to  sink  into 
the  j)laster,  and,  the  borders  of  the  cloth  being  raised,  the  plaster 
is  pressed  against  the  foot  until  rather  more  than  half  is  covered. 
The  foot  should  be  placed  toward  the  higher  side  of  the  chair 
seat,  the  object  of  the  inclined  plane  and  the  lower  surface 
being  to  utilize  the  force  of  gravity  to  hold  the  foot  in  slight 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         733 

adduction.  The  foot  should  be  at  an  angle  with  the  leg,  corre- 
sponding to  its  usual  position  in  the  shoe,  that  is  slightly  plantar 
flexed  and  the  sole  should  be  in  the  plane  perpendicular  to  the 

Fig.  481. 


■ 

^^^^^^^B  -v"''' 

^•^ 

J 

A  cast  marked  for  the  mechanic.  In  most  instances  the  internal  flange  Is 
made  as  in  this  illustration,  as  compared  with  Fig.  485,  In  order  to  strengthen 
the  support  so  that  light  steel   (gauge  20)   may  be  used.      (See  Fig.  485.) 

seat  of  the  chair;  the  toes  need  not  be  included  (Fig.  482).  As 
soon  as  the  plaster  is  hard  its  upper  surface  is  coated  with 
vaseline  or  talcum  powder  and  the  remainder  of  the  foot  is  covered 
with  plaster;  the  two  halves  are  then  removed,  dusted  with 
talcum  powder,  bound  together,  and  filled  with  the  plaster 
cream.     In  a  few  moments  the  outer  shell  may  be  removed,  and 


Fig.  482. 


Fig.  483. 


The  lower  half  of  the   plaster  mould. 


The  plaster  mould  completed. 


one  has  a  reproduction  of  the  foot,  which,  when  properly  made, 
should  stand  upright  without  inclination  to  one  side  or  the  other 
(Fig.  481). 


734 


OBTEOPEDIC   SUSGEBY. 


Fig.  484. 


In  most  instances  it  will  be  of  advantage  to  deepen  in  the 
plaster  model  the  inner  and  outer  segments  of  the  arch,  in  order 
that  the  arch  of  the  brace  maj  be  slightly  exaggerated,  especially 
at  the  heel,  so  that  the  depression  of  the  anterior  extremity  of 
the  OS  calcis  may  be  prevented.  If  the  outer  border  of  the  cast 
is  flattened  by  pressure  a  little  plaster  should  be  added  to  ap- 
jDroximate  the  normal  rounded  contour  of  the  foot. 

The  Brace.- — Upon  the  model  the 
outline  of  the  brace  is  drawn  as 
illustrated  in  the  diagrams.  The 
best  sheet  steel,  18  to  20  gauge, 
cut  after  the  pattern  is  moulded 
upon  it  and  tempered,  so  that  as 
it  is  applied  for  the  purpose  of 
preventing  deformity,  it  may  be 
practically  unyielding  to  the  weight 
of  the  body. 

It  will  be  noticed  that  the  brace 
clasps  the  weak  part  of  the  foot 
and  holds  it  together ;  the  broad 
internal  upright  portion  (Fig. 
481)  covers  and  protects  the  as- 
tragalonavicular  junction,  rising 
well  above  the  navicular;  the  ex- 
ternal arm  covers  the  calcaneo- 
cuboid junction  and  the  outer  as- 
pect of  the  foot  to  a  height  sufiicient  to  hold  the  foot  securely 
(Fig.  484).    The  sole  part  provides  a  firm,  comfortable  support, 


The  outline  of  the  sole  part  of 
the   brace. 


Fig.  48.5. 


Aj  the  astragalonavicular  joint.  The  internal  flange  of  the  brace  should  rise 
well  above  all  the  prominent  bones  to  a  point  abo'it  half  an  inch  below  the 
malleolus. 


DISABILITIES  AND  DEFOEMITIES  OF  THE  FOOT.         735 


yet,  reaching  only  from  the  centre  of  the  heel  to  just  behind  the 
ball  of  the  gi-eat  toe,  it  does  not  restrain  the  normal  motions  of 
the  foot  (Fig.  487).  The  brace  may  be  nickle-plated  which 
makes  a  smooth  finish,  or  galvanized,  which  makes  a  more  dur- 
able covering.  It  may  be  covered  with  leather,  or  an  inner  sole 
may  be  placed  on  its  upper  surface ;  but  this  is  not  usually  neces- 


FiG.  486. 


Fig.  487. 


B,  the  calcaneocuboid  junction.  The  external 
flange  extends  from  the  centre  of  the  heel  to  a 
point  just  behind  the  base  of  the  fifth  metatarsal 
bone. 


C,  the  great  toe-joint ;   D, 
the  centre  of  the  heel. 


sary.  As  it  is  fitted  to  the  foot,  it  finds  and  holds  its  own  place 
in  the  shoe,  so  that  no  attachment  is  required;  thus  it  may  be 
changed  from  one  shoe  to  another.  JSTot  only  does  it  hold  the  foot 
laterally  and  from  beneath,  but  there  is  an  element  of  suggestive- 
ness  in  the  slight  leverage  action  which  is  very  important,  and 
which  is  a  distinctive  feature  of  this  brace  as  contrasted  with 
si'mple  sole  plates  or  other  supports. 

The  Positive  Action  of  a  Proper  Brace. — The  patient,  instructed 
to  throw  his  weight  upon  the  outer  side  of  the  foot  and  wearing 
the  shoe  which  has  been  tilted  in  the  same  direction  by  thicken- 
ing the  inner  border  of  the  sole  and  heel,  presses  down  the  ex- 
ternal arm  and  thus  lifts  the  internal  flange  against  the  inner 
side  of  the  foot,  which  is  instinctively  drawn  away  from  the 
pressure  and  thus  toward  the  normal  contour.  He  no  longer 
turns  the  feet  outward  in  walking,  because  this  causes  positive 
discomfort,  and  he  is  not  likely  to  assume  the  passive  attitude 


736  OETEOPEDIC  SUBGERT. 

because  of  the  suggestive  lateral  pressure  of  the  support.  With 
the  foot  held  in  the  normal  attitude  the  patient  may  again  walk 
with  the  proper  spring ;  thus  the  brace  itself  becomes  a  positive 
aid  in  the  physiological  cure  as  contrasted  with  sole-plates  and 
stiffened  shoes.  It  is  important,  also,  that  a  shoe  of  proper 
shape,  as  shown  in  the  diagram  (Fig.  477),  be  worn,  as  it  aids 
the  brace  in  holding  the  foot  in  an  attitude  of  slight  adduction. 
The  shape  of  the  brace,  in  general  like  that  of  the  diagram,  is 
modified  in  certain  cases ;  for  instance,  the  entire  internal  aspect 
of  the  foot  may  be  weak  and  must  be  covered  by  the  internal 
flange.  In  very  heavy  subjects  the  sole  portion  must  be  made 
larger,  although  this  is  a  disadvantage,  as  it  lessens  the  leverage 
action ;  other  slight  modifications  may  be  necessary  in  special 
cases.  If  any  portion  of  the  rim  of  the  brace  causes  discomfort, 
the  edge  may  be  turned  away  slightly  at  the  point  of  pressure  by 
a  wrench.  After  a  few  days  the  patient  no  longer  notices  the 
constraint  of  the  brace,  and  as  its  presence  in  the  shoe  is  not 
evident,  it  may /be  worn  indefinitely**   Steel  is  the  lightest  and 

Fig.  488. 


The  foot  brace  providing  support  for  tlie  metatarsal  arch. 

strongest,  and,  on  the  whole,  the  most  satisfactory  material  for 
the  brace.  It  will,  of  course,  rust  in  time,  and  for  this  reason 
each  patient  may  be  provided  with  two  pairs  of  braces,  in  order 
that  the  rusted  pair  may  be  returned  to  the  bracemaker  for 
repairs.  In  hospital  practice  heavier  material  is  used  and  the 
braces  are  plated  with  tin,  which  is  fairly  resistant.^ 

Support  is  usually  necessary  for  from  three  months  to  a  year 
or  longer  according  to  the  condition  of  the  patient  and  the  strain 
to  which  the  feet  are  subjected.  The  brace,  accurately  made 
and  adjusted  under  suitable  conditions,  causes  no  more  pressure 

'  In  many  instances  there  is  a  rapid  improvement  in  the  shape  of  the  foot 
under  treatment,  and  it  is  often  advisable  to  make  a  second  cast  within  a 
few  months,  in  order  that  the  brace  may  conform  to  the  improved  contour. 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         737 

or  discomfort  than  a  well-made  shoe,  for  its  principle  is  quite 
different  from  that  of  the  ordinary  supports  that  are  in  common 
use,  to  which  this  objection  has  been  made.  This  brace  sup- 
ports the  arch  primarily  by  preventing  abduction,  consequently 
its  pressure  is  first  felt  upon  the  lateral  aspect  of  the  foot,  a 
pressure  that  the  patient  can  relieve  by  improving  his  attitude. 
The  brace  should  afford  support  when  necessary,  and  at  all  times 
suggest  and  enforce  a  proper  attitude ;  it  is,  however,  but  one  of 
the  essential  factors  in  the  general  scheme  of  treatment.  The 
ordinary  form  of  brace  in  all  its  modifications  conforms  to  the 
shape  of  an  inner  sole  (Fig.  489).     As  it  supports  the  sole  of 

Fig.  489. 


The  sole  plate  ordinarily  used  in  the  treatment  of  weak  foot.      (After  Bradford 

and  Lovett.) 


the  foot,  and  by  the  elevation  of  its  inner  border  tends  to  throw 
the  weight  more  toward  the  outer  side,  it  is  a  useful  aid  in  treat- 
ment ;  but,  providing  no  lateral  support,  it  cannot  prevent  the 
inward  bulging  of  the  foot,  which  is  the  most  important  element 
of  the  deformity,  and  as  compared  to  the  brace  described,  it  is 
therefore  an  ineffective  apparatus. 

In  the  treatment  of  children  the  foot  should  be  moved  in  all 
directions,  but  particularly  in  dorsal  flexion  and  adduction  to 
the  full  limit  at  morning  and  at  night,  until  the  child  has  re- 
gained the  normal  muscular  power  and  ability.  Special  gym- 
nastics and  massage  are  always  desirable,  and  they  may  be  neces- 
sary in  certain  cases.  Bicycling  may  be  cited  as  one  of  the  best, 
and  roller-skating  as  one  of  the  worst  exercises  for  the  weak 
foot.  A  year  is  about  the  time  required  for  a  cure  of  the  weak 
foot  in  childhood,  although  attention  to  the  shoes  and  to  the 
attitudes  must  be  continued  indefinitely. 

THE  RIGID  WEAK  FOOT. 

One  may  now  contrast  with  the  mild  types  of  weakness 
that  have  been  described  the  cases  of  extreme  deformity  in 
which  the  symptoms  are  disabling  and  in  which  the  foot  is 
rigidly  held  in  the  deformed  position  by  muscular  spasm 
and  by  secondary  changes  in  its  structure.  Such  cases,  often 
47 


738  OETHOPEDIC  SUBGEBY. 

considered  hopeless' as  regards  a  cure  or  even  relief,  are  in  reality 
the  most  satisfactory  from  the  remedial  standpoint,  and  in  no 
other  type  of  painful  deformity  can  so  much  be  accomplished  by 
rational  treatment  as  in  this  class.  The  deformity  must  be 
considered  as  a  dislocation  in  which  the  astragalus  has  slipped 
downward  and  inward  from  off  the  os  calcis,  which,  in  turn,  is 
tipped  downward  and  inward  and  into  a  position  of  valgus. 
The  remainder  of  the  foot  is  turned  outward,  so  that  the  relation 
of  the  leg  and  the  forefoot  is  entirely  changed ;  in  fact,  the  fore- 
foot is  almost  entirely  disused  (Fig.  475). 

Corresponding  to  the  duration  of  the  disability,  one  finds 
accommodative  changes  in  the  soft  parts  and  in  the  bones,  but 
such  changes  are  by  no  means  as  marked  as  those  recorded  in  the 
reports  of  autopsies  which  have  been  made  in  cases  of  advanced 
and  irremediable  deformity.  In  fact,  by  far  the  greater  num- 
ber of  patients  are  young  adults  in  whom  the  extreme  deformity 
is  of  comparatively  short  duration,  and  in  whom  complete  cure 
is  possible. 

Treatment. — In  the  treatment  of  such  a  condition  one  must 
first  reduce  the  dislocation  and  overcome  the  obstacles  that  con- 
tracted muscles  and  ligaments  may  offer  to  free  and  normal 
motion;  then  rest  must  be  assured  to  the  injured  and  congested 
parts  in  order  to  relieve  the  patient  from  the  pain  from  which 
he  has  suffered  so  long. 

Forcible  Overcorrection. — By  far  the  most  effective  treatment 
is  forcible  overcorrection  of  the  deformity,  under  anaesthesia. 
When  the  patient  is  under  the  influence  of  the  anaesthetic  the 
muscular  spasm  relaxes,  and  it  will  be  seen  that  this  accounts 
for  about  half  of  the  restriction  of  motion,  the  remainder  being 
caused  by  the  adaptive  changes  that  have  been  mentioned.  The 
object  of  the  operation  is  to  overcome  the  residual  obstruction, 
and  to  assure  the  patient  against  a  relapse,  by  fixing  the  foot 
for  a  sufiicient  time  in  the  position  of  extreme  adduction  and 
supination,  the  attitude  directly  opposed  to  that  which  has  be- 
come habitual. 

This  is  the  object  of  forcible  overcorrection  as  the  first  step  in 
the  systematic  repair  of  the  disabled  mechanism;  its  principle 
must  not  be  confounded  with  forcible  correction  carried  out  with 
the  object  of  simply  remoulding  the  arch  of  the  foot,  or  in  which 
the  correction  of  the  deformity  is  the  only  object  in  view. 

One  first  extends  the  foot  forcibly,  then  flexes  it  to  the  normal 
limit,  then  abducts  and  adducts,  the  different  motions  being 


DISABILITIES  AND  DEFOBMITIES  OF  TEE  FOOT. 


739 


carried  out  over  and  over  until  the  rigid  foot  has  become  per- 
fectly flexible.  In  cases  of  long  standing  it  is  often  necessary  to 
draw  the  patient  to  the  end  of  the  table,  so  that  the  foot  may  be 
taken  between  the  knees,  in  order  to  supply  the  required  force 
by  the  thigh  muscles.  This  forcible  manipulation  is  accompanied 
by  the  audible  breaking  of  adhesions,  and  in  favorable  cases  by 
complete  disappearance  of  the  deformity.  In  certain  instances 
it  will  be  necessary  to  divide  the  tendo  Achillis,  when,  for  ex- 
ample, the  range  of  dorsal  flexion  is  limited  by  resistant  accom- 


FiG.  490. 


Fig.  491. 


The  deformed  foot  before  operation.  A, 
the  projection  of  the  displaced  astragalus 
and  navicular ;  Bj  the  inner  malleolus ;  C, 
the  mediotarsal  joint,  showing  the  outward 
displacement  before,  the  inward  rotation 
behind,  this  point. 


The  overcorrected  foot,  show- 
ing the  reversal  of  the  lines  of 
displacement.      (See  Fig.  490.) 


modative  shortening  of  the  calf  muscles,  or  when  there  has  been 
very  great  pain  and  tenderness  at  the  mediotarsal  joint,  and  it 
is  desired  to  remove  the  strain  of  leverage  completely ;  traumatic 
cases  come  especially  under  this  head.  Occasionally  also  in 
resistant  cases  division  of  the  peronei  tendons  may  be  advisable. 
Tenotomy  has  one  great  advantage :  it  necessitates  longer  fixa- 
tion in  the  plaster  bandage,  and  gives  the  patient  the  benefit 
of  rest,  and  the  opportunity  for  prolonged  after-treatment. 
When  the  passive  range  of  motion  has  been  regained,  the 
foot  is  turned  downward,  then  inward  and  upward  into  the 
position  of  extreme  varus.  By  this  manipulation  the  os  calcis 
is  drawn  under  the  astragalus  and  thrown  into  the  supinated 
position,  and  the  navicular  is  flexed  about  and  under  the  head 
of  the  astragalus,  which  is  then  lifted  to  the  limit  of  normal 


740  OETHOPEDIC   SUBGEEY. 

flexion.  The  attempt  is  always  made  to  bring  the  extreme 
outer  border  of  the  inverted  foot  up  to  a  right  angle  with  the 
leg,  which  is  the  limit  of  normal  flexion  in  this  attitude.  The 
foot,  very  thickly  padded  with  cotton,  especially  between  and 
about  the  toes,  is  then  fixed  in  this  posture  of  varus  by  a  firm 
plaster-of -Paris  bandage  extending  to  the  knee  (Fig.  492). 
Surprisingly  little  discomfort,  considering  the  force  that  it  is 
sometimes  necessary  to  apply,  is  experienced  after  the  opera- 
tion. The  familiar  and  often  intense  pain,  from  which  the 
patient  has  suffered  so  long,  is  entirely  relieved  by  the  cor- 
rection of  the  deformity ;  there  is  often  a  sense  of  tension  about 
the  outer  side  of  the  ankle  and  dorsum  of  the  foot,  but  this  is 
not,  as  a  rule,  of  long  duration. 

Functional  Use  in  the  Overcorrected  Attitude. — As  soon  as  pos- 
sible, often  on  the  following  day,  the  patient  is  encouraged  to 
stand  and  walk,  bearing  his  weight  on  the  foot.  Weight  bearing 
serves  to  still  further  overcorrect  the  deformity  and  to  accustom 
the  patient  to  a  posture  entirely  different  from  that  so  long 
assumed.  Meanwhile,  the  contracted  tissues  on  the  outer  side 
become  thoroughly  overstretched;  the  weakened  ligaments  and 
muscles  on  the  inner  side  are  relaxed,  and  the  local  irritation 
rapidly  subsides  under  the  rest  from  the  constant  injury  to 
which  the  foot  has  been  subjected. 

The  patient  is  not  confined  to  the  bed  or  house,  although  if 
both  feet  are  in  plaster  bandages,  crutches  are,  of  course,  neces- 
sary. The  time  that  the  foot  should  remain  in  the  overcorrected 
position  depends  upon  the  duration  of  the  deformity  and  the 
severity  of  the  symptoms,  from  two  to  six  weeks,  the  usual  time 
being  about  four  weeks.  At  the  end  of  about  three  weeks,  or 
whenever  the  patient  can  support  the  weight  on  the  plaster 
bandage,  without  a  sensation  of  discomfort,  it  is  removed;  the 
foot  is  placed  in  the  normal  attitude  and  a  cast  is  taken  for  the 
brace  (Fig.  480).  Immediately  after,  the  foot  is  returned  to 
the  former  position  and  the  plaster  bandage  is  reapplied.  When 
the  brace  is  ready  the  plaster  bandage  is  finally  removed;  the 
foot  is  now  in  good  position,  and  in  many  instances  the  arch  is 
exaggerated  in  depth.  For  the  first  few  days  prolonged  soak- 
ing in  hot  water  or  the  use  of  the  hot-air  bath,  with  subsequent 
massage  at  intervals  during  the  day,  will  be  found  useful  in 
overcoming  the  swelling  and  sensitiveness  that  may  remain.  It 
is  always  insisted  that  a  new  shoe  of  the  proper  pattern  shall  be 
obtained,  the  sole  and  heel  of  which  are  raised  a  quarter  of  an 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT. 


741 


inch  on  the  inner  border  to  aid  in  the  balancing  of  the  weak  foot. 
The  brace  is  then  applied,  and  the  patient  is  never  allowed  to 
walk  without  its  support.  When  the  shoe  is  removed  at  night, 
he  is  instructed  to  turn  the  toes  in  and  to  bear  the  weight  on  the 
outer  side  of  the  foot  until  it  has  regained  its  strength ;  in  other 
words,  the  deformity  is  never  allowed  to  recur. 
Systematic       Manipulation — 

"rij«      A.QO 

Systematic  treatment  is  then 
begun  by  the  surgeon  and  the 
patient,  with  the  object  of  re- 
storing free  and  painless  pas- 
sive movement  in  all  direc- 
tions. This  movement,  which 
has  been  so  long  restrained  by 
deformity,  cannot  be  regained 
without  effort,  and  during  this 
critical  stage,  treatment  must 
be  carried  out  by  the  surgeon 
himself;  if  he  trusts  to  the 
patient  or  to  his  friends  a  cure 
is  out  of  the  question.  At 
least  once  a  day  the  full  range 
of  motion  must  be  carried  out 
to  the  normal  limit.  Three 
motions — abduction,  flexion, 
and  extension — are  usually 
free  and  painless ;  but  the 
fourth,  that  of  adduction,  is 
almost  invariably  resisted  by 
the  same  quality  of  muscular 
rigidity  that  was  present  be- 
fore the  operation.  Perhaj)s  the  only  effective  method  of  over- 
coming this  resistance  is  conducted  as  follows :  The  patient 
being  seated  in  a  chair,  the  surgeon  sits  or  stands  before  him. 
Let  us  suppose  that  the  right  foot  is  to  be  adducted,  or,  as  the 
patients  express  it,  twisted.  The  surgeon  places  the  foot  be- 
tween his  knees;  his  right  hand  encircles  the  heel,  the  fingers 
grasping  the  projecting  os  calcis  and  tendo  Achillis ;  the  base 
of  the  palm  lies  against  the  mediotarsal  joint  on  the  inner  and 
inferior  aspect  of  the  foot;  the  left  hand  grasps  the  outer  side 
of  the  forefoot  and  toes;  then,  by  steady  pressure  of  the  high 
muscles,   the   forefoot   is   forced   downw^ard   and    inward    (ad- 


The  forcible  overcorrection  of  flat- 
foot.  The  proper  position  in  the  plas- 
ter bandage. 


742 


OETHOPEDIC  SUBGEEY. 


ducted  and  inverted)  (Fig.  493)  over  the  fulcrum  formed  by 
the  projecting  palm,  which  lies  upon  the  right  knee,  the  fingers 
holding  the  heel  steadily  in  place.  This  inward  twisting  is 
at  first  resisted  by  voluntary  and  involuntary  muscular  spasm, 


Fig.  493. 


Twisting  "    the   foot. 


which  gradually  gives  way  under  steady  pressure.  When  the 
limit  of  adduction  has  been  reached,  the  foot  is  held  firmly 
until  all  pain  has  subsided;  then  the  patient  is  instructed  to 
attempt  voluntary  movements  while  the  foot  is  guided  by  the 
hands ;  in  other  words,  the  patient  attempts  to  adduct  the 
foot  while  the  surgeon  supplies  the  power,  which  in  all  cases 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT. 


743 


of  this  type  has  been  completely  lost.  This  passive  manip- 
ulation to  the  extreme  limit  of  normal  adduction,  plantar  and 
dorsal  flexion,  is  continued  from  day  to  day  until  there  is  no 
longer  a  sensation  of  pain  or  tension.  For  as  long  as  there  is 
the  slightest  spasm  or  painful  restriction  of  passive  motion,  the 
voluntary  assumption  of  proper  attitudes  is  checked,  and  until 
this  power  is  regained  there  is  danger  of  relapse.    During  active 

Fig.  494. 


H^^l 

19 

^M^HH 

1 

^^^^^H^^^^RH^^ 

IV 

KID^I 

|H^^HKfeb^^^v^ 

■ii 

hHHHHI 

Method  of  applying  the  plaster  strapping  to  hold  the  foot  in  the  adducted 
attitude.     (See  page  745.) 


treatment,  therefore,  the  patient,  by  means  of  massage  and 
active  and  passive  exercises,  must  constantly  work  to  one  end, 
namely,  to  regain  the  lost  power  of  voluntary  adduction. 

The  time  necessary  to  rest  the  feet,  to  overcome  the  local  irri- 
tation and  muscular  spasm,  to  regain,  in  part  at  least,  the  range 
of  passive  motion,  and  to  place  the  patient  in  the  same  position, 
as  regards  a  cure,  as  in  the  milder  types  of  deformity,  is  from 
three  to  six  weeks.  Usually  the  patients  are  told  that  a  month 
will  be  necessary,  and  that  at  the  end  of  that  time  they  may 
return  to  work,  free  from  pain  and  from  the  danger  of  relapse, 


744  OBTHOPEDIC  SUBGEE¥. 

and  that  the  feet  will  constantly  grow  stronger  under  the  work 
which  was  before  too  great  for  their  strength.  The  time  neces- 
sary to  re-educate  the  adductor  muscles  in  their  proper  function 
depends,  in  great  degree,  upon  the  intelligence  and  persistence  of 
the  patient.  Although  in  after-treatment  massage  and  special 
exercises  are  of  benefit,  the  essentials  are  very  simple ;  they  are 
an  effective  brace,  a  proper  shoe,  the  passive  manipulation  that 
has  been  described  until  its  object  has  been  attained,  and  the 
proper  walk,  the  best  and  easiest  of  exercises.  Finally,  one  must 
force  into  the  patient's  understanding  the  method  of  protecting- 
the  weak  foot  by  the  alternation  of  strain,  and  by  proper  postures. 

Other  Varieties  of  Rigid  Weak  Foot. — The  foot  which  is  fixed 
in  the  abducted  position  without  depression  of  the  longitudinal 
arch  is  simply  one  variety  of  the  rigid  weak  foot,  which  should 
be  treated  in  the  same  manner.  It  may  be  stated,  also,  that  a 
very  large  proportion  of  the  so-called  chronic  sprains  of  the 
ankle  are  of  this  type,  and  that  the  disability  will  yield  very 
readily  to  treatment,  conducted  with  the  purpose  of  restoring 
impaired  function,  in  the  manner  that  has  been  indicated. 

In  certain  instances  the  apex  of  the  deformity  lies  in  front 
of  the  astragalonavicular  joint,  in  the  navicular  cuneiform 
region,  and  the  internal  cuneiform  bone  may  be  enlarged  and 
sensitive  to  pressure.  Such  cases  should  be  treated  on  the  same 
general  principles  as  the  ordinary  variety. 

In  rare  instances  marked  depression  of  the  arch  is  accom- 
panied by  flexion  contraction  of  the  gTeat  toe,  as  if  the  result  of 
an  attempt  to  support  the  weak  arch.  This  was  described  by 
I^icoladoni  as  hammer-toe  flat-foot  (Fig.  476).  The  association 
of  painful  great  toe  (hallux  rigidus)  and  weak  foot  is  men- 
tioned elsewhere  (page  667). 

There  are  other  cases  in  which  the  deformity  of  weak  foot  is 
complicated  by  chronic  rheumatism,  gonorrhoeal  arthritis,  or 
similar  affections  of  which  the  evidence  is  seen  in  various  joints, 
but  in  which  the  pain  and  discomfort  seem  to  be  concentrated 
in  the  feet,  which  are  absolutely  stiff  and  deformed.  In  such 
cases  one  can  hardly  expect  a  complete  cure ;  but  although  the 
function  of  leverage  may  not  be  regained,  still  one  may  hope, 
by  overcoming  the  deformity,  to  hold  the  Aveight  of  the  body  in 
its  proper  relation  to  the  foot,  so  that  the  pain  of  a  progressive 
dislocation  may  not  be  added  to  the  pain  of  disease.  In  a  num- 
ber of  instances  forcible  correction  has  been  employed  by  the 
writer  in  cases  of  this  type,  and  in  all  the  improvement  in  the 


DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT.         745 

general  condition,  consequently  in  the  resistance  to  the  disease, 
after  the  relief  of  the  local  pain  and  discomfort,  has  been  very 
great. 

Between  the  two  classes  of  cases,  the  mild  and  the  severe,  one 
finds  every  grade  of  deformity.  All  cases  in  which  there  is 
marked  muscular  spasm,  local  sensitiveness,  and  swelling  require 
temporary  rest;  in  many  instances  simply  rest  from  functional 
use  combined  with  massage ;  in  others,  rest  in  a  plaster  bandage 
in  the  adducted  attitude.  In  the  milder  and  ordinary  class  of 
cases  the  use  of  a  brace  and  shoe  will  relieve  spasm  and  pain, 
and  the  range  of  motion  can  usually  be  regained  by  manipula- 
tion, passive  motion,  and  by  the  proper  use  of  the  foot. 

Occasionally,  even  in  childhood,  one  may  encounter  marked 
limitation  of  normal  motion,  particularly  in  dorsal  flexion, 
caused  by  actual  shortening  of  the  muscles.  This  may  be  the 
accommodative  adaptation  characteristic  of  long-standing  de- 
formity ;  in  other  instances  it  would  appear  to  be  the  result  of  a 
slight  and  unnoticed  neuritis  or  anterior  poliomyelitis,  which 
has  resulted  in  muscular  inequality.  If  the  contraction  does  not 
yield  readily  to  manipulation  or  to  mechanical  stretching,  forci- 
ble correction  and,  if  necessary,  tenotomy  should  be  employed 
in  the  manner  already  described ;  for  whatever  may  be  the  cause 
it  is  again  emphasized  that  obstruction  to  motion  in  every 
direction  must  be  overcome  before  a  complete  cure  is  possible. 

Adjuncts  in  Treatment. — It  must  be  apparent  that  in  many 
instances  the  anatomical  cure  of  the  weak  foot  is  impracticable, 
either  because  of  the  want  of  energy  or  opportunity  on  the  part 
of  the  patient,  or  because  of  the  local  or  general  conditions,  types 
familiar  in  out-patient  practice. 

The  Thomas  Treatment. — In  such  cases  raising  and  strength- 
ening the  inner  side  of  the  shoe  by  the  wedge-shaped  leather  sole, 
as  used  by  Thomas,  splints  the  painful  foot  and  aids  in  relieving 
the  strain.  A  diagonal  heel  of  which  the  inner  border  extends 
forward  beneath  the  arch  is  a  less  offensive  if  less  effective  sup- 
port of  the  same  class. 

Plaster  Strapping. — If  the  symptoms  are  more  acute  the  adhe- 
sive plaster  strapping,  as  advocated  by  Cottrell  and  Gibney 
for  the  treatment  of  sprains,  is  often  of  service,  although  it  is 
applied  in  a  different  manner,  and  with  a  different  object  in 
view.  One  end  of  a  strip  of  adhesive  plaster,  about  fifteen  inches 
long  and  three  inches  wide,  is  applied  to  the  outer  side  of  the 
ankle  just  below  the  external  malleolus;  the  foot  is  then  ad- 


746  OETHOPEDIC  SUBGEEY. 

-ducted  as  far  as  possible,  and  the  band  is  drawn  tightly  beneath 
the  sole  up  the  inner  side  of  the  arch  and  leg,  and  is  stayed  in 
this  position  by  one  or  two  plaster  strips  about  the  calf  (Fig. 
494).  ITarrow  plaster  straps  are  then  applied  about  the  arch 
and  ankle,  in  the  figure-of-eight  manner,  and  a  bandage  is  ap- 
plied. The  object  of  the  dressing  is  to  aid  in  holding  the  foot 
in  the  improved  position  by  the  support  and  suggestiveness  of 
the  plaster,  and  to  provide  the  firm  compression  about  the  arch 
that  is  always  agreeable  to  the  sufferer  from  weak  foot.  This 
treatment,  combined  with  the  built-up  shoe,  is  often  very  effec- 
tive in  overcoming  the  acute  and  disabling  symptoms  of  the 
weak  and  injured  foot,  which  are,  as  has  been  stated,  often. the 
result  of  extra  strain  or  injury;  in  other  words,  a  sprain  of  a 
weak  foot.  Consequently,  when  these  symptoms  are  relieved, 
the  patient  who  has  become  habituated  to  the  weakness  and  de- 
formity considers  himself  cured.  By  persistent  manipulation 
and  subsequent  support  with  the  adhesive  plaster  one  may 
overcome  the  deformity  in  the  majority  of  cases.  When  this  is 
accomplished  the  brace  is  applied  and  the  further  treatment 
that  has  been  described  is  continued.  Forcible  correction  under 
anaesthesia  is,  however,  preferable  in  cases  of  the  more  resistant 
type. 

Operative  Treatment. — The  various  cutting  operations  for  the 
relief  of  fiat-foot  do  not  call  for  extended  comment.  The  typical 
operation,  the  removal  of  a  wedge  from  the  astragalonavicular 
region,  aims  simply  at  removal  of  the  deformity.  It  should  be 
restricted  to  those  cases  in  which  the  adaptive  changes  are  so 
marked  that  functional  cure  is  impossible. 

The  operation  of  advancement  of  the  posterior  extremity  of 
the  OS  calcis,  as  proposed  by  Gleich,  in  order  that  it  may  be 
placed  in  relation  to  the  leg  somewhat  like  that  of  a  Pirogoff' 
amputation,  offers  little  hope  of  ultimate  cure ;  for  since  the  dis- 
ability is  not  due  to  primary  depression  of  the  arch,  it  can 
hardly  be  cured  by  exaggerating  its  depth  in  this  manner. 
Supramalleolar  osteotomy,  in  which  the  bones  of  the  leg  are 
divided  above  the  ankle,  and  the  distal  extremity  turned  inward, 
with  the  aim  of  directing  the  weight  toward  the  outer  border  of 
the  foot,  has  been  advocated  by  Trendelenburg.  In  practice  the 
operation  is  by  no  means  always  successful,  while  the  bow-leg 
that  results  if  the  object  is  attained  is  an  unfortunate  accom- 
paniment of  the  treatment.  It  may  be  mentioned  in  this  con- 
nection that  fracture  at  the  ankle-joint,  followed  by  faulty  union 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.         747 

in  a  position  of  valgus,  is  a  form  of  traumatic  weak  foot  that 
may  be  cured  by  this  operation.  In  operative  treatment  the 
prolonged  rest  must  be  taken  into  consideration,  as  explaining 
in  part  the  immediate  favorable  effect  of  whatever  procedure  is 
adopted. 

In  conclusion,  the  following  points  are  again  emphasized: 
The  weak  foot  in  all  its  grades  is  characterized  by  the  persistent 
attitude  of  abduction,  an  attitude  that  must  be  corrected  if  cure 
is  to  be  accomplished.  The  depth  of  the  arch  is  of  minor  impor- 
tance and  for  this  reason  the  term  flat-foot  which  has  attracted 
attention  to  this  element  of  deformity  rather  than  to  functional 
disability  should  be  discarded. 


CHAPTEE   XXI. 

DISABILITIES    AND    DEFORMITIES    OF    THE    FOOT    (Contixued). 

THE  HOLLOW  OR  CONTRACTED  FOOT. 

Synonyms. — Talipes  plantaris,  talipes  caviis. 

The  depth  of  the  arch  and  the  corresponding  area  of  the  bear- 
ing snrface  of  the  sole  vary  gTcatly  in  different  individuals,  and, 
although  marked  differences  in  contour  and  function  are  in- 
cluded within  a  normal  range,  yet,  as  a  rule,  the  low  arch  is 
characterized  by  relaxation  and  weakness  of  structure,  while 
the  high  arch  implies  a  corresponding  contraction  and  loss  of 
normal  elasticity. 

The  hollow  or  contracted  foot  may  be  divided  into  two  classes 
— the  primary  and  the  secondary.  In  the  first  class  the  simple 
exaggeration  of  the  arch  (talipes  arcuatus)  is  the  only  change 
from  the  normal  condition.  In  the  second  the  high  arch  is  com- 
bined with  limitation  of  the  range  of  dorsal  flexion  at  the  ankle- 
joint  (talipes  plantaris — Fisher). 

Etiology. — The  simple  hollow  foot  may  be  an  inherited  pecu- 
liarity. The  depth  of  the  arch  may  be  exaggerated  by  the 
habitual  use  of  high  heels  (postural  equinus),  or  by  excessive 
use  of  the  calf  muscles,  as  by  professional  dancers. 

The  secondary  variety,  in  which  the  hollow  foot  is  combined 
with  slight  equinus,  may  be  induced  by  habitual  use  of  high 
heels,  but  if  it  is  marked  its  origin  may  be  traced  in  many  in- 
stances to  a  mild  and  transient  form  of  anterior  poliomyelitis 
or  neuritis  in  early  childhood.  This  causes  temporary  weakness 
of  the  anterior  group  of  muscles  of  the  leg,  and  thus  a  slight 
toe-drop,  followed  by  secondary  contraction  of  the  tissues  of  the 
sole  and  of  the  muscles  of  the  calf.  In  the  history  of  many  of 
these  patients  it  will  appear  that  after  recovery  from  scarlatina 
or  other  contagious  or  infectious  disease  the  child  seemed  weak 
or  awkward.  These  symptoms  became  less  marked  or  practically 
disappeared;  yet  a  trace  remained,  although  not  of  sufficient 
importance  to  call  for  treatment,  until  adolescence  or  adult  life, 
when  the  greater  strain  and  weight  put  upon  the  feet  brought  to 
light  the  latent  disability.  The  affection  may  undoubtedly  de- 
velop in  later  years  as  the  result  of  neuritis,  or  of  gout  or  rheu- 

748 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT. 


749 


matism.  It  may  be  catised  by  a  sprain  or  fracture  of  the  ankle, 
and  it  may  be  a  result  of  habitual  posture  in  compensation  for 
a  limb  shortened  by  injury  or  disease. 

The  exaggerated  arch  which  is  a  part  of  a  more  important 
deformity,  as  of  equinovarus  or  calcaneus,  or  that  which  is 
simply  one  of  many  distortions  caused  by  diseases  of  the  nervous 
apparatus,  does  not  belong  to  the  class  of  disability  under  con- 
sideration. 

Symptoms. — The  simple  hollow  foot  often  exists  without 
symptoms;  in  fact,  it  is  usually  considered  as  a  particularly 

Fig.  495. 


The  contracted  foot  of  slight  degree. 


well-formed  foot  rather  than  a  deformity.  The  common  com- 
plaint in  these  cases  is  that  one  is  unable  to  buy  comfortable 
shoes  because  the  ordinary  shoe  does  not  support  the  arch,  or 
because  the  leather  presses  on  the  dorsum  of  the  foot.  The 
convexity  of  the  dorsum,  of  course,  corresponds  to  the  depth  of 
the  arch;  in  many  instances  the  cuneiform  bones  project  sharply 
beneath  the  skin,  and  painful  pressure  points  or  even  inflamed 
bursse  in  this  locality  may  cause  discomfort. 

In  the  well-marked  cases  in  which  the  weight  is  borne  entirely 


750 


OSTEOPEDIC   SUEGEEY. 


on  the  heel  and  the  front  of  the  foot,  calluses  and  corns  usually 
form  at  the  centre  of  the  heel  and  beneath  the  heads  of  the 
metatarsal  bones.  The  patient  may  complain  of  neuralgic  pain 
about  the  great  toe,  the  metatarsal  arch,  or  in  the  sole  of  the  foot. 
The  gait  is  often  ungraceful,  as  the  patient  walks  heavily  upon 
the  heels  ^vith  the  feet  turned  outward.  In  such  cases  "the 
ankles  may  be  weak  and  turn  easily."  In  the  more  advanced 
cases  of  this  type  the  foot  may  assume  the  position  of  valgus 

Fig.  496. 


The   hollow    foot,    showing    contraction    of   the    toes. 


when  weight  is  borne,  so  that  the  more  noticeable  symptoms  are 
those  of  the  weak  foot  or  so-called  flat-foot. 

Contracted  foot,  of  the  more  severe  grade,  is  almost  always 
accompanied  by  a  certain  limitation  of  dorsal  flexion ;  and  as  the 
shortening  of  the  plantar  fascia  is  often  more  marked  at  its 
inner  border,  a  slight  inversion  of  the  forefoot  or  vartis  may  be 
present  also. 

When  the  exaggerated  arch  is  combined  with  limitation  of 
dorsal  flexion  the  deformity  is  tisually  gTeater.  This  limitation 
may  be  very  slight,  or  it  may  l^e  well-marked ;  and  a  slight  degree 
of  permanent  equinus  even  may  be  present,  but  so  slight  that  it 
does  not.  as  a  rule,  attract  attention. 

This  type  of  the  contracted  foot  was  first  clearly  described  by 


DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT.         751 

Shaffer,  in  1885,  under  the  title  of  "  non-deforming  club-foot,"^ 
and  later  by  Fischer,  of  London,  as  "  talipes  plantaris." 

The  symptoms  are  similar  to  those  of  the  simple  hollow  foot, 
but  they  are  almost  always  more  marked.  The  gait  is  awkward 
and  jarring,  the  feet  being  turned  outward  to  an  exaggerated 
degree.  The  patient  is  easily  fatigued,  and  often  complains  of 
the  weakness  about  the  ankle  and  inner  side  of  the  arch,  charac- 
teristic of  the  weak  foot,  and  of  sensations  of  tire  and  strain  in 
the  calf  of  the  leg.  The  discomfort  from  corns,  the  pain  re- 
ferred to  the  metatarsal  region,  the  great  toe,  and  to  the  sole  of 
the  foot  have  been  described  already. 

On  examination  the  exaggeration  of  the  arch  is  evident,  and 
an  imprint  of  the  sole  shows  that  the  weight  is  borne  entirely  on 
the  heel  and  on  the  heads  of  the  metatarsal  bones,  which  may  be 
very  prominent  beneath  the  thickened  skin,  as  if  the  subcuta- 
neous fat  had  been  absorbed.  The  anterior  metatarsal  arch  is 
often  obliterated,  and  the  toes  are  usually  habitually  dorsiflexed 
at  the  first  phalanges,  the  permanent  flexion,  with  the  resulting 
pressure  against  the  leather  of  the  shoe  being  indicated  by  a  row 
of  corns  upon  their  dorsal  surfaces  (Fig.  496). 

The  contracted  plantar  fascia  may  be  demonstrated  by  forci- 
ble dorsal  flexion  of  the  foot,  when  the  tense  bands,  in  many 
instances  very  sensitive  to  pressure,  may  be  felt  beneath  the  skin. 

On  testing  the  movements  of  the  foot,  the  limitation  of  dorsal 
flexion,  both  of  the  voluntary  and  the  passive  range,  will  be  evi- 
dent. In  voluntary  flexion  the  toes  are  drawn  up  and  the  ten- 
dons are  plainly  seen  on  the  dorsum,  showing  the  effort  made  by 
the  accessory  muscles  to  overcome  the  abnormal  resistance. 

The  limitation  of  dorsal  flexion  may  be  demonstrated  in  the 
manner  suggested  by  Shaffer,  by  asking  the  patient  to  flex  the 
feet  while  standing  erect  with  the  back  to  the  wall,  when,  in 
spite  of  the  effort  made,  "  the  feet  remain  glued  to  the  floor." 

Treatment.- — In  the  ordinary  form  of  contracted  foot,  as  has 
been  stated,  the  disability  is  much  more  marked  than  the  de- 
formity; and  the  disability  is  due  to  secondary  changes  in  the 
structure  of  the  foot,  by  which  its  elasticity  is  impaired.  If  this 
can  be  restored  in  some  degree  permanent  relief  will  follow.  If 
the  simple  hollow  foot  (cavus),  or  the  secondary  type  (plan- 
taris), were  discovered  in  early  childhood,  massage  and  method- 
ical stretching  would,  in  all  probability,  be  sufficient  to  relieve 
the  contractions ;  but,  as  a  rule,  no  symptoms  are  noticed  until 
^  New  York  Medical  Eecord,  May  23,  1885. 


752  OETHOPEDIC  SUEGEBY. 

later  life.  Even  then,  especially  in  the  simple  form,  they  are 
often  slight  and  may  be  relieved  by  a  shoe  with  a  broad  heel  and 
a  high  (Spanish)  arch  or  by  a  foot-plate  that  equalizes  the  pres- 
sure on  the  sole. 

In  the  more  advanced  cases  of  the  milder  type  methodical 
forcible  manual  stretching  may  elongate  the  tissues  sufficiently 
to  relieve  the  symptoms.  The  Shaffer^  "  traction  shoe  "  may  be 
used  with  advantage  for  the  same  purpose.  In  the  more  resist- 
ant cases,  however,  division  of  the  contracted  parts  and  forcible 
correction  of  deformity  are  indicated. 

Operative  Treatment. — The  patient  having  been  anaesthetized, 
a  tenotomy  knife  is  introduced  beneath  the  skin  to  the  inner  side 
of  the  central  band  of  fascia.  This  is  divided  by  a  sawing 
motion,  and  if  on  forced  dorsal  flexion  other  tense  bands  appear 
they  are  divided  also.  Forcible  massage,  with  the  aim  of  mak- 
ing the  foot  flexible  and  reducing  the  depth  of  the  arch,  is  then 
employed.  If  more  force  is  required  the  Thomas  wrench  may 
be  used  as  in  the  treatment  of  club-foot;  the  object  being  to 
elongate  the  foot,  to  remove  the  contraction,  and  thus  by  increas- 
ing the  area  of  bearing  surface  to  relieve  the  painful  pressure 
on  the  heads  of  the  metatarsal  bones.  If  the  contraction  of  the 
tenclo  Achillis  cannot  be  overcome  by  forcible  manipulation  it 
may  be  divided.  In  nearly  all  cases  of  this  type  the  toes  are 
contracted  often  to  a  degree  of  hammer-toe  deformity  and  the 
metatarsal  arch  is  replaced  by  a  convexity  downward.  This 
deformity  may  be  corrected  by  subcutaneous  division  of  the 
extensor  tendons.  The  toes  are  then  vigorously  stretched  and  are 
then  forced  downward,  while  the  metatarsal  extremities  are 
pushed  upward.  A  plaster  bandage  is  then  applied  to  hold  the 
extended  toes  in  plantar  flexion  and  the  foot  in  dorsal  flexion. 
A  thin  board  may  be  incorporated  in  the  bandage,  in  order  that 
firm  and  even  pressure  may  be  exerted  upon  the  sole.  As  soon 
as  possible,  often  on  the  following  clay,  the  patient  is  encouraged 
to  walk  about,  in  order  that  the  pressure  of  the  body  weight  may 
be  utilized  to  flatten  the  foot  still  more,  while  its  tissues  are  in  a 
yielding  condition. 

The  bandage  may  be  continued  for  six  weeks,  or,  if  the  tendo 
Achillis  has  been  divided,  until  its  repair  is  complete.  A  well- 
fitting  shoe  should  be  worn,  and  methodical  massage  and  stretch- 
ing of  the  tissues  should  be  persistently  employed.  A  long 
metal  foot  plate  worn  within  the  shoe  j)resenting  a  convexity 
'New  York  Medical  Journal,  March  5,  1887. 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         753 

beneath  the  metatarsophalangeal  articulations  aids  in  restoring 
the  normal  contour. 

By  this  treatment  the  symptoms  may  be  relieved,  and  in 
many  instances  a  return  to  the  normal  shape  and  function  can 
be  assured. 

WEAKNESS  AND  DEPRESSION  OF  THE  ANTERIOR  META- 
TARSAL ARCH. 

Anterior  Metatarsalgia  and  Morton's  Neuralgia. — A  peculiar 
spasmodic  pain  about  the  fourth  toe  was  described  by  Morton, 
of  Philadelphia,  long  before  its  predisposing  and  exciting  causes 
were  understood.  For  this  reason  a  description  of  the  symp- 
toms may  with  advantage  ]3recede  a  consideration  of  the  weak- 
ness of  which  they  are  usually  the  result. 

Typical  cases  of  Morton's-^  painful  affection  of  the  foot  are 
characterized  by  a  sudden  cramp-like  pain  in  the  region  of  the 
fourth  metatarsophalangeal  articulation. 

The  pain  may  begin  as  a  burning  sensation  beneath  the  toe, 
as  a  numb  or  tingling  feeling,  as  a  sudden  cramp,  or  as  a  pecu- 
liar feeling  of  discomfort  about  the  articulation  that  increases 
in  severity  until  it  becomes  almost  unbearable.  At  first  the  jDain 
is  confined  to  the  neighborhood  of  the  affected  joint,  but  unless 
it  is  relieved  it  radiates  to  the  extremity  of  the  toe,  to  the  dor- 
sum of  the  foot,  or  up  the  leg.  In  many  instances  the  onset  of 
the  pain  is  preceded  by  the  sensation  of  something  moving  or 
slipping  in  the  foot ;  in  some  cases  the  pain  may  be  induced  by 
sudden  movements,  misstejDS,  or  by  long  standing,  and  in  prac- 
tically all  the  cases  the  pain  is  felt  only  when  the  shoes  are 
worn.  The  frequency  of  the  recurrent  cramp  varies ;  in  some 
cases  it  appears  only  at  infrequent  intervals ;  in  others  it  prac- 
tically disables  the  patient.  When  the  "  cramp  "  habit  has  been 
acquired,  very  slight  causes  may  induce  the  pain — for  example, 
a  thin-soled  shoe,  a  hot  pavement,  "the  sticking  of  the  sock  to 
the  foot,"  and  the  like — but,  as  has  been  stated,  except  in  the 
very  advanced  and  chronic  cases,  the  pain  is  never  felt  except 
when  the  shoe  is  worn. 

To  relieve  the  pain  the  patient  removes  the  shoe,  rubs  and 
compresses  the  front  of  the  foot,  flexes  and  extends  the  toes,  and 
the  like.  After  the  cramp  is  relieved  a  sensation  of  soreness 
remains,  and  occasionally  slight  swelling  may  appear,  but  in 

^  T.  G.  Morton,  American  Journal  of  the  Medical  Sciences,  August,  1876. 
48 


754  OBTHOPEDIC  SUEGEBY. 

most  instances  there  are  no  external  signs,  although  the  affected 
articulation  is  usually  sensitive  to  deep  pressure  at  all  times. 

The  more  comprehensive  term,  anterior  metatarsalgia,  a  term 
sugg-ested  by  Poulosson,  of  Lyons,  in  1889,  may  be  employed 
to  include  Morton's  neuralgia,  and  similar  symptoms  of  pain 
and  discomfort  about  the  anterior  metatarsal  arch.  For  in  many 
instances  the  cramp-like  pain  is  referred  to  other  points,  for  ex- 
ample, to  several  adjoining  joints,  or  the  discomfort  caused 
apparently  by  direct  pressure  on  the  bones  of  the  weakened  arch 
may  be  more  disabling  than  the  irregular  attacks  of  neuralgic 
pain  characteristic  of  Morton's  affection. 

Etiology  and  Pathology, — In  78  cases  of  anterior  metatarsalgia 
in  which  the  location  of  the  pain  was  noted,  it  was  referred  to 
the  fourth  metatarsophalangeal  articulation  in  60.;  to  the  third 
and  fourth  articulation  in  6 ;  to  the  second,  third,  and  fourth 
in  6,  and  in  but  6  was  the  fourth  articulation  free  from  pain. 
The  pain  is  most  often  unilateral,  or,  if  the  second  foot  is 
affected,  it  is  usually  after  a  considerable  interval. 

The  affection  is  more  common  in  females  than  in  males.  Of 
84  cases,  64  were  in  women  and  20  were  in  meii. 

Anterior  metatarsalgia  is  not  an  affection  of  early  life,  the 
average  age  in  the  reported  cases  being  more  than  thirty  years. 
It  is  far  more  common  in  private  than  in  hospital  practice,  and 
not  infrequently  the  patients  are  of  a  distinctly  nervous  type. 
In  many  instances  it  is  supposed  to  be  a  family  inheritance. 
The  affection  is  usually  extremely  chronic.  Occasionally  the 
symptoms  may  cease  spontaneously,  and  in  such  instances  a 
particular  pattern  of  shoe  usually  receives  the  credit  of  the  cure. 

Morton  considered  the  disability  to  be  a  painful  affection  of 
the  plantar  nerves  due  to  compression  or  pinching  by  the  ad- 
joining fourth  and  fifth  metatarsophalangeal  articulations.  This 
compression  was  explained  by  the  anatomical  construction  of 
the  foot — i.  e.,  the  mobility  of  the  fifth  metatarsal  bone  which 
allowed  it  to  roll  above  and  under  the  fourth,  its  relative  short- 
ness which  allowed  the  head  and  base  of  the  adjoining  phalanx 
to  be  brought  against  the  adjoining  head  and  neck  of  the  fourth 
bone,  and,  finally,  by  the  peculiar  distribution  of  the  external 
plantar  nerve  between  these  bones  that  made  it  or  its  fibres  more 
liable  to  injury.  This  natural  mobility  and  thus  the  predisposi- 
tion to  compression  might  be  exaggerated  by  a  sprain,  or  pos- 
sibly by  rupture  of  the  transverse  metatarsal  ligament,  or  the 
pain  might  be  induced  by  wearing  tight  shoes,  but  in  many  in- 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.         755 

stances  no  cause  could  be  assigned.  On  this  theory  Morton 
advocated  excision  of  the  head  of  the  fourth  metatarsal  bone  to 
remove  the  point  of  counter-pressure.  This  operation  has  been 
performed  many  times,  but  practically  no  pathological  changes 
in  the  resected  bone  or  in  the  surrounding  parts  have  ever  been 
discovered. 

In  more  recent  years  the  true  significance  of  Morton's  neu- 
ralgia and  of  similar  pains  in  the  front  of  the  foot  has  been  made 
more  clear  by  the  study  of  the  relation  of  v^eakness  of  the 
anterior  transverse  metatarsal  arch  to  the  symptoms.  Attention 
wsis  first  called  to  this  point  by  Poulosson,  and  again  by  Rough- 
ton,  Woodruff,  and  others,  and  in  a  much  more  thorough  and 
convincing  manner  by  Goldthwait/  in  1894. 

The  Anterior  Metatarsal  Arch. — In  the  normal  foot  the  two 
central  metatarsal  bones,  the  second  and  third,  are  slightly  longer 
and  on  a  higher  plane  than  their  fellows.  On  the  sole  of  the 
foot  the  arch  is  shown  by  the  depression  on  the  outer  side  of  the 
muscular  projection  of  the  great  toe-joint.  When  weight  is 
borne  all  the  metatarsal  bones  are  on  the  same  plane  and  the 
arch  is  obliterated  but  when  the  weight  is  removed  the  arch  is 
restored  by  certain  natural  resiliency.  In  walking  and  stand- 
ing the  weight  falls  in  the  neighborhood  of  the  head  of  the  third 
metatarsal  bone,  as  shown  by  a  thickening  of  the  skin  beneath 
it,  but  the  strain  on  the  metatarsal  arch  is  relieved  somewhat  by 
the  balancing  action  of  the  muscles  about  the  first  and  fifth 
metatarsal  bones,  the  inner  and  outer  supports  of  the  arch,  and  by 
the  active  assistance  of  the  toes  themselves.  When  the  arch  is 
weak  or  broken  down  this  natural  resiliency  is  lost,  and,  in  some 
instances,  the  centre  of  the  forefoot  is  not  only  depressed  but  it 
is  fixed  in  this  abnormal  attitude. 

In  the  ordinary  type  of  depressed  anterior  arch  the  deformity 
may  be  shown  by  an  imprint  of  the  foot,  in  which  the  flabby 
tissues  of  the  depressed  arch  encroach  upon  the  clear  space  rep- 
resenting the  longitudinal  arch.  In  many  instances,  however, 
the  imprint  of  the  foot  subject  to  Morton's  neuralgia  may  be  to 
all  intents  normal,  and,  on  the  other  hand,  depression  of  the 
metatarsal  arch,  one  of  the  very  common  results  of  improper 
shoes,  may  be  present,  yet  unaccompanied  by  pain  or  discomfort. 

Depression  of  the  anterior  arch  predisposes  to  pain  because 
of  abnormal  pressure  upon  the  persistently  depressed  articula- 
tions from  beneath  and  it  predisposes  to  pain,  as  the  writer  has 
^  Boston  Medical  and  Surgical  Journal,  vol.  cxxxi.,  p.  233, 


756 


OJRTHOPEDIC  SUBGEBY. 


endeavorecP  ■  to  explain,  because  the  metatarsophalangeal  joints 
of  an  habitually  depressed  arch  are  exposed  to  the  direct  lateral 
compression  of  a  narrow  or  ill-shaped  shoe. 

This  point  may  be  illustrated  in  the  hand.  When  lateral 
pressure  is  applied,  the  hand  is  folded  together  and  the  anterior 
metacarpal  arch  is  increased  in  depth,  but  if  the  fingers  are 
dorsiflexed  so  that  it  is  fixed  in  a  depressed  position,  then 
lateral  compression  causes  great  pain  at  all  the  articulations 
(Fig.  49 Y)  ;  or  if  one  finger  is  dorsiflexed  and  the  corresponding 
metacarpal  bone  is  thus  forced  below  the  level  of  its  fellows. 

Fig.  497. 


Position  of  the  fingers   corresponding  to  dorsiflexion  of  the  toes,   an   attitude  in 
which   lateral    pressure    causes    pain. 


lateral  compression  causes  pain  at  the  compressed  joint.  Or  if 
the  metacarpal  bone  of  the  little  finger  is  made  to  over-ride  the 
fourth,  lateral  pressure  causes  pain  usually  of  a  more  acute 
character  than  at  the  other  joints,  because  the  opportunity  for 
direct  pressure  is  more  favorable."  Finally,  if  firm  pressure  is 
made  upon  one  or  the  other  side  of  the  head  of  the  depressed 
metacarpal  bone  of  the  dorsiflexed  finger  in  the  palm  of  the 
hand,  a  point  of  sensitiveness,  representing  apparently  the 
digital  nerve,  can  be  made  out.  The  same  experiments  may  be 
tried  upon  the  foot  with  the  same  results,  and  it  would  seem  to 
make  clear  the  mechanism  of  the  pain  of  Morton's  neuralgia  and 
the  allied  forms  of  discomfort  at  the  front  of  the  foot. 

Anterior  mctatarsalgia  is  in  most  instances  the  result  of  weak- 

1  New  York  Medical  Record,  August  6,  1898. 

^  This  anatomical  jjeeuliarity  is  well  known  to  school-boys. 


DISABILITIES  AND  DEFOEMITIES  OF  THE  FOOT.         757 

ness  or  depression  of  the  anterior  metatarsal  arch  as  a  whole  or 
in  part,  and  the  quality  of  the  pain  corresponds  fairly  to  the 
form  of  weakness  or  deformity.  If,  for  example,  the  entire  arch 
is  rigidly  depressed,  as  after  certain  inflammatory  affections  of 
the  joints,  the  discomfort  is  likely  to  be  caused,  in  great  degree, 
by  the  direct  pressure  of  the  sensitive  depressed  metatarso- 
phalangeal joints  on  the  sole  of  the  shoe;  or,  if  lateral  pressure 
is  exerted  as  well,  the  discomfort  or  pain  may  be  referred  to  the 
metatarsal  arch  in  general.  If  the  metatarsal  arch  is  weakened, 
depressed,  and  broadened,  but  not  rigid,  the  discomfort  is  often 
referred,  as  in  the  preceding  instance,  to  the  centre  of  the  arch, 
and  this  discomfort  is  increased,  in  some  instances,  by  a  painful 
callus  representing  abnormal  pressure  at  this  point.  If  one  of 
the  metatarsal  bones  falls  below  its  fellows,  the  lateral  pressure 
of  a  narrow  shoe  may  cause  neuralgic  pain  at  this  joint,  but  in 
many  cases  in  which  the  anterior  arch  is  depressed  the  patient 
makes  but  little  complaint  of  pain.  In  certain  instances,  more 
particularly  those  of  Morton's  typical  neuralgia,  the  foot  may 
appear  to  all  intents  normal;  in  such  cases  it  may  be  inferred 
that  the  sharp  and  characteristic  pain  is  caused  by  pressure  ap- 
plied to  the  over-riding  fifth  metatarsal  bone,  just  as  similar 
pain  is  felt  if  the  hand  is  suddenly  compressed  while  the  fifth 
metacarpal  bone  is  in  the  same  position.  The  theory  is  the  more 
probable  when  one  considers  the  symptoms ;  for  example,  the 
sensation  of  something  slipping  or  moving,  the  necessity  for  the 
removal  of  the  shoe  to  flex  and  extend  the  toes  and  to  compress 
the  foot,  apparently  with  the  instinctive  aim  of  replacing  a  de- 
pressed arch,  or  a  misplaced  bone  in  the  arch.  It  would  also 
explain  how  the  shoe  may  be  the  most  direct  of  the  exciting 
causes  of  the  deformity,  in  that  it  compresses  the  forefoot  and 
throws  more  weight  upon  it  by  elevating  the  heel.  If  the  arch 
is  depressed  or  becomes  depressed,  or  if  the  bone  in  the  arch 
overrides  another,  this  compression  causes  the  symptoms. 

Classical  Morton's  neuralgia  is  then  but  one  of  the  symptoms 
of  weakness  of  the  anterior  arch  of  the  foot. 

The  Influence  of  the  Shoe  in  Causing  Disability  and  Pain. — In  the 
etiology  of  pain  and  discomfort  about  the  anterior  arch  one 
must  recognize  the  shoe  not  only  as  the  direct  cause  of  the  pain, 
but  also  as  the  most  important  of  the  predisposing  causes  of  weak- 
ness of  the  anterior  arch,  of  which  the  pain  is  a  symptom,  since 
it  compresses  the  toes,  lifts  them  off  the  ground  by  its  "  rocker 
sole,"  and  thus,  by  preventing  their  normal  function,  throws 


758  OBTHOPEDIC  SURGE  BY. 

additional  strain  and  pressure  upon  the  arch.  In  fact,  in  a  very 
large  proportion  of  feet  that  are  supposed  to  be  normal  in  ap- 
pearance and  functional  ability,  the  toes  are  habitually  dorsi- 
flexed  in  a  claw-like  attitude,  that  shows  entire  disuse  of  their 
function  both  as  to  support  and  progression.  Women  wear 
shoes  with  narrower  soles  and  higher  heels  than  men,  and  this 
seems  the  most  reasonable  explanation  of  the  fact  that  they  are 
more  subject  to  the  affection. 

The  shoe  also  predisposes  to  habitual  elevation  of  the  fifth 
metatarsal  bone,  because  this  bone  almost  invariably  overhangs 
the  narrow  sole.  The  fourth  metatarsal  bone  becomes,  there- 
fore, the  outer  sujjport  of  the  arch,  and  is  almost  always  found 
to  be  on  a  lower  level  than  the  adjoining  bones.  This  relation, 
together  with  a  laxity  of  muscular  and  ligamentous  support  in- 
duced by  injury  or  otherwise,  may  account  for  the  location  of 
the  pain  at  this  point  in  the  majority  of  cases.  Although  in 
certain  instances  local  neuritis  may  result  from  repeated  injury, 
it  is  a  rather  unusual  complication.  I*^or  is  it  likely  that  the 
peculiar  distribution  of  the  nerves  at  the  fourth  joint  has  any 
direct  influence  on  the  location  of  the  pain,  for  the  nerve  supply 
of  all  the  joints  and  all  the  toes  is  practically  identical. 

Other  Factors  in  the  Etiology. — Besides  the  general  effect  of  the 
shoe,  and  the  influence  of  an  inherited  predisposition  to  the 
affection,  which  seems  evident  in  certain  cases,  or  of  weakness 
or  direct  injury  of  the  anterior  arch,  one  recognizes  among 
the  causes  or  complications  of  anterior  metatarsalgia  weakness 
of  the  longitudinal  arch,  which  may  be  combined  with  a  de- 
jDression  of  the  anterior  arch.  Less  often  the  longitudinal  arch 
may  be  exaggerated  in  depth  and  the  dorsal  flexion  of  the  foot 
may  be  limited  by  a  shortened  tendo  Achillis  ;  thus  more  pressure 
is  brought  upon  the  front  of  the  foot.  In  these  cases  the  pain 
may  be  increased  by  corns  or  calloused  skin  beneath  the  de- 
pressed bones,  and  in  many  instances  the  discomfort  of  the  de- 
pressed arch  of  the  ordinary  type  is,  in  great  part,  caused  by  a 
sensitive  corn  or  fibroma  at  the  point  of  greatest  depression,  and 
the  patient  may  be  entirely  relieved  by  its  removal.  (See  Con- 
tracted Foot.) 

Although  the  symptoms  of  anterior  metatarsalgia  may  be 
explained  in  most  instances  by  the  primary  effect  of  improper 
shoes,  by  weakness  and  abnormality  of  the  foot  itself,  and  by  the 
local  sensitiveness  of  the  parts  that  are  continually  subjected  to 
strain,  pressure,  and  injury,  yet  in  some  instances  the  symptoms 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         759 

can  be  accounted  for  only  by  local  neuritis ;  in  others  they  are 
aggravated  by  gout  or  rheumatism  or  general  debility,  and  as 
has  been  mentioned  in  a  large  proportion  of  the  cases,  the 
patients  are  of  a  distinctly  nervous  type. 

It  may  be  stated,  in  conclusion,  that  anterior  metatarsalgia 
in  its  milder  forms  is  a  very  common  affection  and  one  rarely 
treats  a  patient  who  does  not  know  of  other  cases  similar  to  his 
own. 

Treatment. — The  most  important  local  treatment  is  to  provide 
the  patient  with  a  suitable  shoe.  This  shoe  must  be  of  proper 
shape  with  a  thick  sole,  so  broad  that  no  lateral  compression  of 
the  toes  is  possible,  with  a  high  arch  and  narrow  counter,  so 
that  the  leather  fitting  closely  about  and  beneath  the  arch  may 
hold  the  foot  securely. 

As  an  immediate  treatment  a  firm  bandage  about  the  meta- 
tarsal region,  as  suggested  by  Morton,  may  aid  in  supporting 
the  metatarsal  arch,  or,  better,  adhesive  plaster  strapping  may 
be  applied  about  the  entire  metatarsus,  with  the  object  of  com- 
pressing the  fore-foot  somewhat  as  a  tight  glove  compresses  the 
hand.  Beneath  or  slightly  behind  the  affected  joint  or  the  de- 
pressed arch,  a  pad,  preferably  an  oval  piece  of  sole-leather, 
about  one  inch  by  three-quarters  of  an  inch  in  size  and  one- 
quarter  in  thickness  with  bevelled  edges,  may  be  fixed  to  the 
sole  of  the  foot  with  adhesive  plaster  so  that  depression  of  the 
arch  or  over-riding  of  the  adjoining  bones  may  be  prevented. 
This  pad,  suggested  by  Poulosson  and  Goldthwait,  usually  re- 
lieves the  pain,  and  when  the  exact  place  has  been  ascertained  it 
may  be  fixed  to  the  sole  of  the  shoe. 

As  a  rule,  however,  a  metal  support  will  be  found  to  be  more 
comfortable  and  far  more  efficient.  This  may  be  constructed 
of  light  steel  (19  gauge)  upon  a  plaster  cast  of  the  sole  of  the 
foot.  The  anterior  extremity  of  the  brace  is  made  nearly  as 
wide  as  the  foot,  and  extends  forward  slightly  beyond  the  meta- 
tarsophalangeal articulations.  As  a  rule,  a  slight  general  con- 
vexity is  efficient,  but  in  certain  instances  this  must  be  greatest 
behind  the  sensitive  joint  to  relieve  the  pain.  The  brace  should 
also  support  the  longitudinal  arch  to  hold  the  foot  securely  and 
to  relieve  some  of  the  pressure  on  the  metatarsal  region.  In 
certain  instances  one  or  more  of  the  metatarsophalangeal  articu- 
lations may  be  sensitive  to  motion.  In  such  cases  the  plate  must 
extend  from  the  heel  to  the  extremity  of  the  sole  in  order  to 
splint  the  foot  for  a  time.     If  there  is  slight  depression  of  the 


760 


OETHOPEDIC   SUPiGEEY. 


longitudinal  arch  it  may  be  further  corrected  by  raising  the 
inner  border  of  the  heel  and  sole  of  the  shoe ;  but  if  it  is  more 
pronounced  a  flat-foot  brace  (Fig.  488)  may  be  employed,  whose 
anterior  extremity  is  modified  to  support  the  metatarsal  arch. 


Fig.  498. 


Exercise   for   the   weakened   metatarsal    arch. 

If,  on  the  otherhand,  the  arch  is  exaggerated  and  if  dorsal  flexion 
is  limited,  treatment  with  the  aim  of  relieving  this  deformity  will 
be  necessary,  as  described  under  "  contracted  foot."  When  the 
immediate  symptoms  of  pain  and  local  discomfort  have  been 
relieved,  the  patient  must  endeavor  to  strengthen  the  natural 
supports  of  the  arch  by  proper  functional  use  of  the  foot,  and  by 
regular  exercises  of  the  muscles,  more  especially  by  methodical 
forced  flexion  of  the  toes,  as  this  motion  elevates  the  anterior 
metatarsal  arch  (Fig.  498).  Massage  of  the  foot  and  forcible 
manipulation  of  the  toes  for  the  purjDose  of  overcoming  restric- 
tion of  motion  are  of  special  value. 

If  the  depressed  anterior  arch  is  rigid,  as  in  some  instances, 
its  flexibility  must  be  restored  by  manipulation  or  by  forcible 
correction  under  anaesthesia  before  a  brace  can  be  applied.  If 
the  symptoms  are  very  acute,  and  jDarticularly  if  they  have  fol- 
lowed direct  injury,  the  parts  should  be  placed  at  rest  and  the 
anterior  arch  should  be  elevated  and  supported  by  a  properly 
applied  plaster  bandage. 

In  chronic  and  resistant  cases  or  when  conservative  treatment 
cannot  be  applied,  resection  of  the  neck  and  head  of  the  meta- 
tarsal bone  at  the  seat  of  pain  may  be  jDcrformed  as  advocated  by 
Morton.  The  operation  is  very  simple.  An  incision  is  made 
over  the  dorsal  surface  of  the  joint,  and  the  bone  is  divided  by 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.         761 

bone  forceps  or  Gigli  saw.  The  toe  is  not,  as  a  rule,  removed, 
but  after  the  operation  it  slowly  recedes  between  the  adjoining 
metatarsophalangeal  joints,  becoming  somewhat  shorter.  The 
operation  is,  as  a  rule,  successful,  but  in  the  majority  of  cases 
it  is  unnecessary. 

The  general  condition  of  the  patient  should,  of  course,  receive 
attention,  and  local  applications,  electricity,  and  the  like,  may 
be  of  benefit  in  special  cases. 

A  sensitive  callus  beneath  the  arch  may  require  treatment, 
and  in  certain  cases  its  removal  may  be  the  only  treatment  re- 
quired other  than  an  improved  shoe.  But,  as  a  rule,  the  cause 
of  the  callus  is  habitual  depression  of  one  or  more  of  the  meta- 
tarsophalangeal articulations,  so  that  cure  can  only  be  assured 
by  supporting  the  arch  and  by  strengthening  its  natural  sup- 
ports. If  as  in  certain  instances  the  depressed  joint  cannot  be 
replaced  in  normal  position  the  head  of  the  metatarsal  bone  must 
be  removed. 

Woodruff^  described  a  case  of  what  he  called  "  incomplete 
luxation  of  the  metatarsophalangeal  articulation,"  in  which  the 
symptoms,  practically  identical  with  those  of  Morton's  neu- 
ralgia, are  ascribed  to  an  upward  displacement  of  the  proximal 
phalanx  at  the  fourth  metatarsophalangeal  joint. 

It  may  be  stated  in  this  connection  that  in  the  ordinary  forms 
of  metatarsalgia  patients  often  refer  the  pain  and  local  sensi- 
tiveness to  the  anterior  extremity  of  the  metatarsal  bone  rather 
than  to  its  lateral  aspect.  Persistent  dorsal  flexion  of  the  toes 
that  is  so  commonly  associated  with  depression  of  the  arch  by 
subjecting  this  portion  of  the  joint  to  abnormal  pressure,  may 
explain  the  location  of  the  pain.  But  except  in  extreme  cases 
it  can  hardly  be  classed  as  a  subluxation. 

ACHILLOBURSITIS. 

Synon3nais. — Achillodynia,  achillobursitis  anterior,  retrocal- 
caneobursitis. 

Under  the  title  of  Achillodynia,  Albert,^  in  1893,  called  par- 
ticular attention  to  an  affection  characterized  by  pain  and  sen- 
sitiveness about  the  insertion  of  the  tendo  Achillis,  symptoms 
usually  caused  by  irritation  or  inflammation  of  the  small  bursa 
lying  between  the  insertion  of  the  tendon  and  the  bone  (Fig. 
499). 

^  New  York  Medical  Eecord,  January  18,  1887. 
^Wiener  med.  Presse,  January  8,  1893. 


762  OBTHOPEBIC  SUBGEBY. 

Etiology.- — In  the  acute  cases  the  cause  of  the  bursitis  often 
appears  to  be  a  strain  of  the  tendon  or  direct  injury,  as  the 
symptoms  appear  immediately  after  running  or  jumping  or 
after  a  f all^  sometimes  after  a  long  walk  or  bicycle  ride. 

In  the  subacute  cases  the  symptoms  may  begin  almost  imper- 
ceptibly, so  that  it  may  be  impossible  to  assigii  a  direct  cause 
other  than  the  pressure  of  the  shoe,  ag- 
■^^^"-  ^^^-  gravated,  it  may  be,  by  an  exostosis  of  the 

OS  calcis  beneath  the  insertion  of  the 
tendon  or  by  concretions  within  the 
bursa.  In  many  instances  rheumatism, 
gout,  gonorrh(Pa,  or  one  of  the  infectious 
diseases  appear  to  be  associated,  directly 
or  indirectly,  with  the  onset  of  the  symp- 
toms, or  the  bursa  may  be  secondarily 
involved  in  tuberculous  disease  of  the  os 
calcis. 

Sjmaptoms — In  a  typical  case  pain  is 
felt  in  the  back  of  the  heel  at  the  inser- 

Bursa       between       the  .  „     ,  ,  ,  ...  , 

tendo  Achiiiis  and  the  os     tiou  ol  the  tcudou ;  the  pain  IS  increased 
calcis.  ]3j  nse  of  the  foot,  and  particularly  by 

the  attitudes  in  which  the  strain  on  the 
part  is  increased,  as,  for  examj^le,  in  descending  stairs.  There 
is  also  sensitiveness  to  pressure  about  the  back  of  the  heel 
on  either  side  of  the  insertion  of  the  tendon.  In  most  cases  a 
slight  swelling,  often  more  prominent  on  the  inner  than  the 
outer  side  of  the  tendon,  indicates  the  situation  of  the  bursa. 

In  the  chronic  cases  the  enlargement  of  the  bursa  is  very 
noticeable,  and,  in  addition,  the  entire  posterior  aspect  of  the 
heel  often  appears  to  be  thickened.  This  is  due  probably  to  the 
secondary  irritation  abou.t  the  fibrous  expansion  of  the  tendon 
and  the  adjoining  periosteum.  In  many  cases  the  symptoms  are 
pronounced;  pain  is  often  felt  in  the  bottom  of  the  heel  or  it 
radiates  up  the  back  of  the  leg.  The  patient,  unable  to  use  the 
power  of  the  calf  muscle,  everts  the  foot  in  walking,  thus  sub- 
jecting the  arch  to  overstrain,  so  that  the  symptoms  of  the  weak 
foot  are  often  added  to  those  of  the  original  trouble.  ISTot  infre- 
quently, however,  the  two  affections  may  be  associated  from  the 
beginning  in  one  or  the  other  foot.  The  jjatient  complains  much 
of  stiffness  and  weakness  at  the  ankle  and  tarsal  joints.  In  acute 
cases,  or  in  acute  exacerbations,  there  is  usually  burning  and 
throbbing  pain  characteristic  of  inflammation,  but  in  the  sub- 


DISABILITIES  AND  DEFOEMITIES  OF  TEE  FOOT.         763 

acute  form  the  pain  is  slight,  and  is  troublesome  only  after 
overexertion. 

Pathology. — The  pathological  changes  do  not  differ  from  those 
found  in  and  about  other  bursse  under  similar  conditions.  In 
the  mild  cases  the  lining  membrane  is  simply  congested,  and  the 
cavity  contains  serous  fluid.  In  the  chronic  cases  the  walls  are 
much  thickened/  the  lining  membrane  is  fringed  and  redupli- 
cated; the  contents  are  semisolid,  and  sometimes  calcareous 
masses  are  present.  Similar  changes  are  found,  however,  in  the 
bursse  of  apparently  normal  subjects,  so  that  the  condition  of 
the  bursa  may  not  always  correspond  to  the  character  of  the 
symptoms.  Suppuration  of  the  sac  occasionally  occurs,  and  it 
may  be  the  seat  of  tuberculous  or  syphilitic  disease.  In  cases  of 
long  standing  the  jDarts  adjoining  the  bursa,  the  expansion  of 
the  tendon,  and  the  periosteum  become  thickened,  so  that  the 
bone  appears  to  be  increased  in  breadth  and  may  actually  be- 
come so. 

Treatment. — When  once  established  the  affection  is  usually 
of  a  very  chronic  nature,  as  is  explained  by  the  strain  to  which 
the  sensitive  j)art  is  subjected  by  the  use  of  the  footi  It  is, 
therefore,  important  to  apply  efficient  treatment  at  the  begin- 
ning of  the  affection  if  an  opportunity  is  afforded.  Efficient 
treatment  im23lies  absolute  rest,  and  in  all  cases  of  any  severity, 
particularly  those  of  acute  onset,  a  well-fitting  plaster  bandage 
should  be  applied  to  hold  the  foot  slightly  inverted  and  at  a 
right  angle  to  the  leg.  This  should  be  worn  until  all  symptoms 
have  subsided.  In  very  mild  cases,  following  immediately  on 
a  strain  or  overuse,  simple  rest  with  the  application  of  heat, 
massage,  and  pressure  may  be  efficient.  And  in  the  subacute 
cases  the  symptoms  may  be  relieved  by  the  application  of  a 
long,  broad  band  of  adhesive  plaster,  from  the  toes  over  the  back 
of  the  heel  to  the  upper  third  of  the  calf,  the  foot  being  slightly 
plantar  flexed.  This  is  firmly  fixed  by  narrow  strips  of  plaster 
about  the  metatarsus,  the  heel,  and  the  calf.  By  this  means 
pressure  is  exerted  upon  the  bursa,  and  much  of  the  strain  is 
removed  from  the  tendon. 

In  persistent  cases  a  brace  may  be  used  with  advantage  for 
the  purpose  of  preventing  strain  upon  the  tendon.  Two  lateral 
uprights  with  a  calf  band  and  padded  strap  that  crosses  the 
upper  third  of  the  leg  are  attached  to  the  shoe,  provided  with  a 
stop  joint  at  the  ankle  as  used  in  the  treatment  of  paralytic 
1  Eossler,  Deut.  Zeit.  f .  Chir.,  Bd.  Ixii.,  H.  1  and  3. 


764  OSTEOPEDIC   SUEGEBY. 

calcaneus  to  prevent  dorsal  flexion.  (See  Talipes.)  As  the 
patient  is  usually  sensitive  to  jar,  the  heel  of  the  shoe  should  be 
rej^laced  by  one  of  thick  rubber.  In  connection  -with  the  brace 
the  stimulation  of  the  cautery  and  the  pressure  of  the  adhesive 
plaster  strapping  seem  to  hasten  the  absorption  of  the  effusion 
in  and  about  the  bursa.  If  weakness  or  depression  of  the  arch  is 
present,  as  a  result  of  the  disability  or  combined  with  it,  a  foot- 
plate should  be  ajjplied,  and  general  affections,  with  which  the 
disability  is  sometimes  associated,  should,  of  course,  receive 
attention. 

Operative  Treatment. — In  persistent  cases,  in  which  the  symp- 
toms are  not  relieved  by  treatment,  the  enlarged  bursa  should  be 
removed  by  an  incision  on  the  inner  side  of  the  tendon,  as  the 
swelling  is  usually  most  prominent  here.  A  plaster  bandage  is 
then  applied  and  is  continued  until  the  symptoms  have  subsided. 
If  the  case  is  a  chronic  one,  it  may  be  advisable  to  divide  the 
tendo  Achillis  in  order  to  completely  remove  for  a  time  the  strain 
upon  the  sensitive  part.  A  brace  of  the  character  already  de- 
scribed may  be  used  with  advantage  for  a  time  after  the  plaster 
support  has  been  removed.  Operative  treatment  is,  of  course, 
indicated  in  acute  suppurative  inflammation,  in  tuberculous  dis- 
ease, or  if  an  exostosis  beneath  the  bursa  or  concretions  within 
the  sac  are  present,  as  shown  by  an  X-ray  negative. 

Achillobursitis  Posterior. — Tenderness,  pain,  and  swelling  at 
the  back  of  the  heel  may  be  due  to  inflammation  of  the  small 
superficial  bursa  that  lies  between  the  tendon  and  the  skin. 
The  cause  is  usually  injury  or  the  pressure  of  the  shoe.  The 
symptoms  resemble  somewhat  those  of  achillobursitis  anterior, 
but  the  swelling  is  more  superficial,  and  the  pain  is  caused  by 
direct  pressure  rather  than  by  tension  on  the  tendo  Achillis. 
In  the  ordinary  case  removal  of  the  jDressure  will  at  once  relieve 
the  symptoms,  but  if  the  discomfort  is  considerable  a  plaster 
bandage  may  be  worn  for  a  week  or  more. 

Sensitive  points  at  the  back  of  the  heel  are  usually  caused  by 
the  pressure  of  the  shoe.  In  rare  instances  prominent  points  or 
exostoses  of  the  os  calcis  are  present,  that  may  require  special 
protection  or  removal. 

STRAIN  OF  THE  TENDO  ACHILLIS. 

Not  infrequently,  and  usually  as  the  result  of  strain  or  over- 
use of  the  foot,  patients  complain  of  symptoms  similar  to  those 
of  achillobursitis,  but  on  examination  one  finds  that  the  pain 


DISABILITIES  AND  DEFOEMITIES  OF  THE  FOOT.         765 

and  sensitiveness  are  referred  to  the  tendon  itself  (peritendi- 
nitis). There  is  no  swelling  at  its  insertion,  or  pain  on  lateral 
pressure  on  the  os  calcis.  The  sensitive  area  may  be  as  high  up 
as  the  junction  of  the  tendon  with  the  muscle,  and,  again,  the 
midpoint  of  the  tendon  seems  most  painful. 

The  cause  in  some  cases  may  be  a  direct  strain  of  the  tendon 
or  of  the  muscular  fibres  near  its  origin,  or  inflammation  of  its 
fibrous  covering  due  probably  to  the  same  cause.  The  treatment 
is  similar  to  that  of  the  milder  type  of  achillobursitis,  by  the 
adhesive  plaster  straj)ping,  by  rest,  and,  later,  by  massage. 
Recovery  is  usually  rapid. 

PAINFUL  HEEL— CALCANEOBURSITIS. 

Pain  referred  to  the  bottom  of  the  heel  and  sensitiveness  to 
pressure  on  standing  are  common  symptoms  of  the  weak  or  flat- 
foot.  Pain  at  this  point  may  be  one  of  the  symptoms  of  achillo- 
bursitis also.  In  rare  instances  the  painful  point  is  clearly 
localized,  and  is  confined  to  a  small  area  in  the  neighborhood  of 
the  inner  tuberosity  of  the  os  calcis.  The  cause  of  the  symptoms 
in  such  cases  may  be  an  inflamed  bursa  lying  between  the  perios- 
teum and  the  fatty  tissue  of  the  heel.  Painful  heels  are  a  not 
uncommon  complication  of  gonorrhoea  and  in  cases  of  long  stand- 
ing the  local  inflammation  apparently  beginning  in  the  musculo- 
periosteal  attachment  of  the  flexor  brevis  cligitorum  may  result 
in  ossification  (exostosis).  Projections  of  bone  in  this  locality 
are  often  seen  in  X-ray  pictures  of  normal  feet  and  in  many 
instances  a  weakened  or  depressed  arch  is  the  exciting  cause  of 
pain  which  an  exostosis  merely  aggravates.-^ 

More  general  pain  and  sensitiveness  referred  to  the  heel  are 
often  the  result  of  direct  pressure  and  bruising  of  the  tissues 
incidental  to  overuse  of  the  feet. 

Treatment. — Treatment  must  be  directed  to  the  condition  of 
which  the  pain  is  a  symptom,  and,  as  has  been  stated,  it  is  most 
often  one  of  the  symptoms  of  the  weak  or  broken-down  arch. 
If  the  sensitive  point  is  localized,  and  if  the  pain  is  increased  by 
jars,  a  thick  rubber  heel  combined  with  an  inner  sole,  so  cut  out 
as  to  remove  the  direct  pressure  on  the  sensitive  point,  will  often 
relieve  the  symptoms.  In  persistent  cases,  in  which  the  sensitive 
point  is  distinctly  localized,  operative  intervention  for  the  re- 
moval of  the  bursa  or  exostoses  is  indicated. 

^  Baer,  Surgery,  Gynecology,  and  Obstetrics,  July  2,  1906. 


766  ORTHOPEDIC  SVEGEMY. 

Sensitiveness  due  to  direct  contusion,  or  bruising  of  the  tissues 
caused  by  overuse,  must  be  treated  by  rest  and  by  change  of 
occupation,  unless  reduction  of  the  body  weight  or  improve- 
ment in  attitudes  and  local  support  relieve  the  symptoms. 

PLANTAR  NEURALGIA. 

Synonjon. — Plantalgia. 

Pain  referred  to  the  sole  of  the  foot  and  sensitiveness  to  pres- 
sure on  the  plantar  fascia  are  usually  symptomatic  of  the  con- 
tracted foot  (cavus)  ;  less  often  such  symptoms  accompany  the 
weak  or  broken-down  arch. 

Pain,  tenderness,  and  thickening  of  the  fascia  sometimes  fol- 
low injury  (rupture  of  the  fascia )}  and  a  similar  condition  has 
been  described  by  Franke  as  one  of  the  sequelae  of  influenza.^ 
It  may  be  present,  also,  in  the  patients  who  suffer  from  gout  or 
rheumatism. 

Treatment. — Pain  in  the  sole  of  the  foot,  symptomatic  of  the 
contracted  or  of  the  weak  foot,  may  be  relieved  by  the  treatment 
of  the  conditions  of  which  it  is  a  symj)tom.  In  the  rare  instances 
in  which  the  fascia  is  itself  injured  or  diseased,  local  rest,  as 
afforded  by  the  plaster  bandage,  is  indicated  until  the  acute 
symptoms  have  subsided. 

VASOMOTOR  TROPHIC  NEUROSES. 

Under  this  title  may  l^e  included  angioneurotic  oedema,  acro- 
paresthesia, erythromelalgia,  and  the  like  aft'ections,  functional 
rather  than  organic,  and  due  to  disturbance  of  the  sympathetic 
system. 

Erythromelalgia. — Erythromelalgia  is  of  more  direct  interest 
since  it  is  characterized  by  attacks  of  heat,  redness,  pain,  and 
often  swelling,  most  marked  about  the  soles  of  the  feet.  Dis- 
turbances of  the  circulation  and  burning  pain  in  the  soles  of  the 
feet  are  common  symptoms  of  the  weak  foot  and  of  allied  affec- 
tions, but  in  such  cases  there  is  not  the  flushing  and  swelling 
characteristic  of  erythromelalgia.  In  this  affection  the  circula- 
tory disturbances  are  not,  as  a  rule,  confined  to  the  feet,  but  are 
seen  in  the  legs  and  even  in  the  upper  extremities.^  It  deserves 
mention  as  a  possible  explanation  of  symptoms  in  obscure  cases.* 

'Lederhose.  Verhand.  der  Deut.  G.  f.  Chir..  XXIII.  Kong.,  1894. 
-  Arehiv  f.  klin.  Chir..  1895.  Bd.  xlix. 
^Kahane.  Klin,  therap.  Wochen.,  May  20,  1900. 

*  Prentiss,  Transactions  of  the  Association  of  American  Physicians,  1897, 
vol.  xii.,  p.  303. 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         767 

DYSBASIA  ANGIOSCLEROTICA:^  INTERMITTENT  LIMP. 

The  title  indicates  a  sclerotic  change  apparently  the  result  of 
a  chronic  inflammation  which  may  involve  the  veins  as  w^ell 
as  the  arteries  in  the  bloodvessels  by  which  the  nutrition  of 
the  foot  is  impaired.  The  supply  of  blood  is  not  equal  to  the 
necessities  of  activity,  thus  the  patient,  comfortable  when  at 
rest,  after  walking  may  begin  to  limp,  or  on  standing  to  suffer 
from  stiffness,  numbness,  and  pain  in  the  limbs  and  feet.  On 
examination  one  notes  that  the  feet  are  cold,  cyanotic,  or  of  a 
dark-red  color,  and  that  the  circulation  is  impaired.  In  more 
advanced  cases  the  sclerotic  changes  in  the  arteries  are  apparent 
on  palpation  and  this  may  be  demonstrated  in  certain  instances 
by  X-ray  pictures.  The  pain  continues  at  night  after  activity 
during  the  day.  It  usually  becomes  severe  and  continuous  be- 
fore necrosis  appears.  It  is  described  because  it  is  often  mis- 
taken for  the  symptoms  of  flat-foot.  In  my  own  experience  the 
cases  of  a  severe  type  have  been  in  adult  male  Jews. 

The  only  effective  treatment  from  the  symptomatic  stand- 
point is  to  adapt  the  activity  of  the  patient  to  his  blood  supply. 
A  period  of  absolute  rest  is  most  effective  in  relieving  pain, 

HALLUX  RIGIDUS. 

Synonyms. — Hallux  flexus,  painful  great  toe. 

Hallux  rigidus  is  a  painful  affection  of  the  great  toe-joint, 
characterized  by  restriction  of  motion,  particularly  of  the  range 
of  dorsal  flexion.  In  advanced  cases  the  first  phalanx  may  be 
slightly  plantar  flexed,  together  with  its  metatarsal  bone ;  hence 
the  name  hallux  flexus,  applied  by  Davies-Colley,  who  first  de- 
scribed the  affection. 

The  restriction  of  motion  may  be  complete,  as  implied  by  the 
term  rigidus;  the  joint  appears  unduly  prominent  or  enlarged, 
usually  slightly  congested,  and  pressure  or  forced  movement 
causes  pain. 

The  symptoms  of  which  the  patient  complains  are  a  burning 
or  throbbing  pain  in  the  joint,  increased  by  standing,  and  par- 
ticularly by  walking,  because  of  the  enforced  movement  of  the 
stiff  and  painful  articulation.  There  are  many  cases  in  which 
there  is  no  actual  deformity  of  the  joint  or  other  noticeable 
change;  the  restriction  of  motion  is  much  less,  and  the  symp- 
toms are  correspondingly  slight. 

^  Erb,  Miincb    med,  Woeh.,  1904,  No.  2. 


768 


OBTHOPEDIC   SURGERY. 


Fig.  500. 


Etiology. — Typical  hallux  rigidus  is  most  common  in  adoles- 
cence, and  it  is  very  often  associated  with  the  weak  or  broken- 
down  foot.  In  snch  cases  the  toe  is  forced  into  the  narrow  part 
of  the  shoe,  and  is  thus  subjected  to  lateral  and  to  longitudinal 
j>ressure,  as  well  as  to  the  additional  strain  that  the  attitude, 
characteristic  of  the  weak  foot,  throws  upon  it.  In  some  cases 
the  habitual  plantar  flexion  of  the  toe  may 
be  the  result  of  an  instinctive  effort  to 
support  the  weak  arch  (hammer-toe  flat- 
foot — N^icoladoni).  In  other  instances 
hallux  rigidus  is  caused  directly  by  trau- 
matism, as  by  stubbing  the  toe,  by  kick- 
ing a  hard  object,  or  by  other  form  of 
strain  or  injury.  The  affection  appears 
to  be,  primarily,  a  form  of  periarthritis, 
caused  by  injury  or  pressure.  The  re- 
striction of  motion  is  in  part  due  to  mus- 
cular spasm,  and  in  part  to  the  irritative 
and  accommodative  changes  in  the  liga- 
ments and  tendons.  In  more  advanced 
cases  changes  in  the  cartilage  and  shape 


The  dotted  outliBe 
shows  the  shape  of  the 
steel  splint  that  may  be 
inserted  in  the  sole  of 
the  shoe  for  hallux  rig- 
idus. 


of  the  articulating  surfaces,  due  to  disuse 


of  function  and  to  pressure  and  friction, 
may  be  present. 

Treatment. — If  the  rigid  and  painful  joint  is  not  associated 
with  a  weak  arch,  it  may  be  relieved  by  providing  the  patient 
with  a  proper  shoe  which  exerts  no  pressure  on  the  sensitive 
part.  Motion  of  the  joint  may  be  lessened  by  increasing  the 
thickness  of  the  sole,  or,  if  necessary,  it  may  be  entirely  re- 
stricted by  the  insertion  of  a  brace  of  tempered  steel  between 
the  two  layers  of  the  sole,  as  shown  in  the  diagram  or  by  a  sole 
plate  within  the  shoe.  If,  as  in  some  instances,  the  ffexed  and 
painful  toe  is  associated  with  rigid  flat-foot,  both  deformities 
may  be  overcorrected,  under  anaesthesia,  and  retained  in  proper 
position  by  a  plaster  bandage,  as  a  preliminary  treatment. 

If  the  milder  type  of  painful  joint  is  associated  with  the  ordi- 
nary weak  foot,  the  treatment  of  the  latter  condition  will  usually 
relieve  the  symptoms.  In  this  class,  particularly  among  the 
poorer  patients,  the  shoe  may  be  raised  on  the  inner  side  and 
the  sole  stiffened  by  means  of  the  wedge-shaped  sole,  as  already 
described  in  the  treatment  of  the  weak  and  flat-foot.  If  painful 
motion  is  restricted,  and  if  the  exciting  causes  of  the  disability 


DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT.         769 

are  removed,  relief  of  the  symptoms  is  usually  immediate.  In 
the  chronic  cases,  in  which  the  pathological  changes  are  more 
advanced,  excision  of  the  joint  may  be  necessary. 

PAINFUL  GREAT  TOE-JOINT  IN  OLDER  SUBJECTS. 

A  similar  condition  of  the  joint  is  sometimes  found  in  older 
subjects.     In  many  instances  the  foot  is  well-formed,  and  the 

Fig.  501. 


Hallux  rigidus  and  flat-foot,  showing  the  persistent  flexion  of  the  toe  on  the 
metatarsal  bone. 

restriction  of  motion  in  the  joint  is  very  slight ;  yet  forced  dorsal 
flexion  causes  pain,  and  long  standing  or  walking  induces  dis- 
comfort, particularly  a  dull  ache  in  the  joint  and  sharp  neuralgic 
pain  referred  to  the  terminal  phalanx.  In  some  cases  the  onset 
of  the  symptoms  may  be  ascribed  to  a  long  walk  or  "  mountain 
climb,"  in  others  to  wearing  tight  shoes,  and  in  some  instances 
no  definite  cause  can  be  assigned  by  the  patient.  In  cases  of 
this  type  the  symptoms  are  often  supposed  to  be  evidences  of 
gout  or  rheumatism  and  in  certain  instances  there  is  a  distinct 
hypertrophic  change  corresponding  to  Heberden's  nodes  on  the 
fingers.  Although  in  certain  instances  the  discomfort  may  be 
aggravated  by  a  constitutional  disease,  still  no  relief  can  be  ob- 
49 


770 


OBTHOPEDIC  SUBGEBY. 


tained  by  medication  unless  it  is  combined  with  the  local  treat- 
ment that  has  been  described  in  the  preceding  section.  The 
relief  afforded  by  such  treatment  alone  proves,  in  many  in- 
stances, that  the  affection  is  purely  local  in  its  character  (Fig. 
501). 

As  has  been  mentioned,  pain  referred  to  this  joint  is  a  com- 
mon symptom  of  the  weak  foot  and  of  the  contracted  foot  as  well. 

Fig.  502. 


■  Simple  congenital  varus,  adduction  without  inversion — a  form  of  pigeon-toe. 

It  is  also  caused  by  simple  pressure  on  the  joint,  and  by  the  use 
of  improper  shoes  which  force  the  toes  into  the  abducted 
position. 

In  rare  instances  pain  directly  beneath  the  great  toe  and 
sensitiveness  to  pressure  about  the  sesamoid  bones  seem  to  indi- 
cate an  inflammation  of  the  tendon  sheath  or  local  periarthritis. 
If  the  discomfort  is  persistent  the  sesamoid  bones  may  be  re- 
moved. As  a  rule,  such  symptoms  occur  only  in  combination 
with  pain  or  deformity  of  the  great  toe-joint.  If  the  extremity 
of  the  metatarsal  bone  is  enlarged  and  if  pain  persists  excision 
is  advisable. 

HALLUX  VARUS. 

Adduction  of  the  great  toe  is  not  infrequent  in  infancy,  and  it 
may  be  associated  with  a  slight  degree  of  varus  deformity  (Fig. 
503).  The  peculiarity  attracts  the  mother's  attention  because 
of  the  difficulty  of  drawing  on  the  socks.    In  many  instances  the 


BIS  ABILITIES  ANB  BEFOBMITIES  OF  THE  FOOT. 


Ill 


Fig.  503. 


adductor  muscles  seem  abnormally  developed,  and  the  toe  ap- 
pears to  be  somewhat  prehensile  in  its  movements. 

Treatment. — The  abnormal  mobility  may  be  checked  by  en- 
closing the  toes  v^^ith  a  narrow  strip  of  adhesive  plaster ;  in  any 
event,  the  ordinary  shoe  may  be 
depended  upon  to  correct  any  resi- 
dual deformity  of  this  character. 
If  the  adducted  toe  is  combined 
with  varus,  the  deformity  must 
be  corrected  in  the  ordinary  man- 
ner.    (See  Talipes.) 

PIGEON-TOE. 

Congenital  hallux  varus  forms 
one  variety  of  what  is  known  as 
pigeon-toe  or  the  habitual  turning 
in  of  the  feet  in  walking.  The  in- 
ward rotation  may  be  due  also  to 
bow-legs,  or  it  may  be  an  effect  of 
congenital  talipes  that  persists 
after  the  cure  of  the  deformity,  or 
of  the  exceptional  variety  of  coxa 
vara  in  which  the  depressed  necks 
of  the  femora  are  turned  forward. 
In  most  instances,  however, 
pigeon-toe  in  childhood  is  symp- 
tomatic of  weakness  either  of  the 
arch  of  the  foot  or  of  the  knees 
(genu  valgum).  In  such  cases  it 
is  a  conservative  effort  of  nature 
to  check  further  deformity,  and  it 
needs  no  treatment  other  than  that 
which  may  be  applied  to  the  weak- 
ness or  deformity  of  which  it  is 
a  symptom. 

In  the  exceptional  cases,  in  which  the  posture  is  not  sympto- 
matic of  weakness  or  the  effect  of  deformity,  the  sole  of  the  shoe 
may  be  raised  slightly  on  the  outer  border.  This  will  correct  the 
attitude  in  the  milder  type,  if  combined  with  instruction  and 
training.     In  rare  instances  the  in-toeing  seems  to  be  caused  by 


An  appliance  constructed  of 
leather  bands  and  elastic  webbing 
for  the  correction  of  in-toeing. 
Name  of  the  inventor  unknown. 


772 


OBTHOPEDIC   SUEGEEY. 


Fig.  504. 


limitation  of  the  range  of  outward  rotation  at  the  hip-joints,  a 
restriction  that  must  be  overcome  by  systematic  stretching  of 
the  contracted  parts.  In  these  and  in  the  more  obstinate  cases 
of  the  simple  type  apparatus  may  be  applied,  similar  to  that 
used  in  the  after-treatment  of  congenital  club-foot,  to  hold  the 
feet  in  the  proper  attitude   (Fig.  503).     It  must  be  borne  in 

mind  that  the  proper  attitude  of  the 
feet  is  one  of  jDarallelism  not  of  out- 
ward rotation,  and  that  slight  pigeon- 
toe  will,  as  a  rule,  correct  itself  as  the 
child  grows  older. 

METATARSUS  VARUS. 

This  i.-  a  deformity  in  which  the 
metatarsus  is  adducted  on  the  tarsal 
bones.  It  may  be  congenital  as  in 
talipes  varus,  in  slight  degree  it  may 
Ije  a  compensatory  effect  of  valgus  de- 
formity or  knock-knee  and  it  may  be 
an  accompaniment  of  valgus  deformity 
of  the  posterior  division  of  the  foot. 
Adduction  of  the  first  metatarsal  bone 
is   a  constant  accompaniment  of  hal- 

Metatarsus  varus.  luX  valgTlS    (Fig.   504). 


HALLUX  VALGUS. 

Hallux  valgus  is  a  deformity  in  which  the  gTcat  toe  is  turned 
outward  to  an  exaggerated  degree.  Outward  deviation  of  the 
toe  is  so  common,  induced  by  the  shoe,  that  it  is  not  recognized 
as  a  deformity,  at  least  from  the  popular  standpoint,  unless  the 
joint  appears  to  be  much  ''•'  enlarged."  forming  a  so-called  bunion. 

Hallux  valg-us  is  practically  a  partial  dislocation  of  the 
phalanx  upon  the  metatarsal  bone.  In  well-marked  cases  the 
metatarsal  bone  is  adducted  or  turned  inward,  so  that  an  ab- 
normal interval  separates  its  head  from  its  fellows,  while  the 
phalanx  is  displaced  outward  and  articulates  only  with  the  outer 
condyle.  The' angle  thus  formed,  or,  more  properly,  the  inner 
condyle  of  the  adducted  metatarsal  bone,  makes  the  prominent 
or  "outgrrjwn"  joint  (Fig..  517).  This  projects  sharply  be- 
neath the  skin,  and  is  exposed  to  injury  and  to  the  pressure  of 
the   shoe;   thus   a   bursa    develops   Ijeneath  the   skin,   while   a 


DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT.         773 

corn  or  callus  forms  on  its  superficial  surface.  The  projecting 
bone,  covered  by  tbe  irritated  bursa  and  the  thickened  skin, 
makes  up  the  bunion. 

In  many  instances  the  other  toes  are  displaced  outward,  in 
the  direction  corresponding  to  that  of  the  great  toe  and  in  such 
cases  all  the  metatarsal  bones  are  somewhat  adducted,  or  this 
may  be  rotated  on  its  long  axis  and  lie  above  or  beneath  its 
fellows.  As  a  secondary  effect  the  forefoot  is  broadened  and  the 
metatarsal  arch  is  lost.  The  deformity  is  often  combined  with 
weak  foot  although  in  many  instances  the  arch  is  of  normal 
height. 

Pathology. — The  pathological  changes  are  such  as  usually 
follow  deformity,  disuse  of  function,  and  injury;  The  cartilage 
on  the  exposed  condyle  atrophies,  the  sesamoid  bones,  together 
with  the  tendon,  are  displaced  outward,  the  tissues  on  the  outer 
side  undergo  accommodative  shortening,  while  those  on  the  inner 
side  are  correspondingly  lengthened  and  attenuated.  The  sur- 
face of  the  bone  beneath  the  irritated  periosteum  is  often 
roughened  and  irregular,  and  exostoses  may  form  about  the  con- 
dyle, and  thus  aggTavate  the  effects  of  the  lateral  pressure. 

Etiology. — The  deformity  is  the  direct  effect  of  shoes  that  are 
too  narrow  and  of  improper  shape,  and  in  some  instances  too 
short  for  the  foot,  so  that  the  great  toe  is  subjected  to  lateral 
and  longitudinal  pressure.  The  deforming  effect  of  the  shoe  is 
increased  if  the  arch  is  weak,  so  that  the  toe  is  forced  forward 
into  the  narrower  part  of  the  shoe  when  the  foot  is  in  use.  The 
deformity  may  be  increased  by  injury  or  by  the  changes  that 
follow  gout,  rheumatism,  infectious  arthritis  and  the  like,  and 
in  rare  instances  the  distortion  may  be  the  direct  result  of  such 
diseases;  but  all  other  factors  are  of  slight  importance  when 
compared  to  the  deforming  influence  of  the  ordinary  shoe.  The 
deformity  begins  at  a  very  early  age ;  it  advances  more  rapidly 
during  adolescence,  but  the  symptoms  do  not  often  become 
troublesome  until  later  years.  Both  toes  are  affected,  as  a  rule, 
although  the  deformity  and  its  accompanying  symptoms  are 
usually  more  marked  on  one  side. 

Symptoms. — As  has  been  stated,  the  slighter  grades  of  de- 
formity are  not  recognized  as  such,  and  it  is  usually  because  of 
the  pain  due  to  the  irritated  corn  or  bursa,  and  incidentally 
because  of  the  outgrown  joint,  that  the  patients  apply  for 
treatment. 


774  OBTEOPEDIC  SUBGEBY. 

Treatment. — The  sjmjDtoms  in  the  ordinary  cases  may  be 
relieved  by  providing  a  proper  shoe,  by  which  pressure  on  the 
joint  is  completely  removed  (Figs.  477  and  514).  The  sole 
should  be  strong,  and  it  should  be  slightly  thicker  along  the 
inner  side,  so  that  the  sensitive  joint  may  be  inclined  away  from 
the  upper  leather.  In  cases  in  which  the  deformity  is  not  far 
advanced  the  use  of  a  suitable  shoe  that  allows  space  for  an  im- 
proved position  of  the  great  toe,  combined  with  methodical 
manual  correction  of  the  deformity  and  exercise  of  the  disused 
muscles  while  the  toe  is  guided  in  the  proper  directions  by  the 
fingers,  will  relieve  the  symptoms  promptly  and  lessen  the  de- 
formity. If  the  longitudinal  or  the  metatarsal  arches  are  de- 
pressed they  should  be  j)roperly  supported  (Figs.  485  and  488). 

Several  forms  of  correcting  braces  have  been  devised,  to  be 
worn  during  the  day,  a  digitated  stocking  and  special  shoe  be- 
ing, of  course,  necessary. 

A  simple  device  for  holding  the  toe  in  an  improved  position 
is  the  Holden  toe-post,  recommended  by  Walsham  and  Hughes. 
This  is  a  thin  piece  of  metal  so  fixed  in  the  front  and  inner  side 
of  the  sole  of  the  shoe  that  it  separates  the  first  and  second  toes 
from  one  another  and  holds  the  former  in  an  improved  position. 
It,  of  course,  necessitates  a  sj^ecial  shoe  and  a  special  shoemaker 
to  fit  it  in  its  proper  place. 

Sampson^  makes  the  toe-post  of  tin  and  places  it  in  a  card- 
board inner  sole,  as  illustrated  in  the  diagrams  (Figs.  505  to 
508). 

The  use  of  a  splint  at  night  is  also  of  some  service.  For  this 
purpose  a  piece  of  celluloid  about  one-eighth  inch  in  thickness, 
one  inch  in  width,  and  about  six  inches  in  length  may  be  used. 
This,  having  l^een  moulded  to  the  proper  contour  by  placing  it  in 
hot  water,  is  secured  by  tapes  to  the  inner  side  of  the  toe  and  foot. 

It  may  be  stated  that  in  the  class  of  cases  that  can  be  success- 
fully treated  by  mechanical  correction  very  few  patients  will  be 
found  who  are  sufficiently  interested  in  the  cure  of  the  deformity 
to  submit  to  the  slight  discomfort  that  the  wearing  of  even  a 
carefully  adjusted  brace  entails. 

Operative  Treatment. — In  cases  in  which  the  deformity  is  of 
long  standing,  and  in  which  the  projecting  condyle  or  the 
exostoses  make  protection  of  the  sensitive  joint  difficult,  an 
operation  is  indicated.  The  primary  object  of  the  operation  is 
to  remove  the  projecting  bone.  This  may  be  accomplished  by  a 
^  Johns  Hopkins  Bulletin,  January,  1902. 


DISABILITIES  AND  DEFOBMITIES  OF  TEE  FOOT. 


716 


slightly  curved  incision  about  the  inner  aspect  of  the  condyle, 
the  centre  being  below  the  joint,  so  that  the  scar  will  not  be  sub- 


FiG.  505. 


H 


D 


B 


Making  the  pattern  for  a  toe-post.  A  heavy  piece  of  paper  folded  once  along 
the  line  AB,  ADE  and  BCF  are  cut  away,  leaving  the  tongue  ADCB.  AD  should 
equal  the  depth  of  the  shoe  at  that  point,  and  AB  should  be  as  wide  as  the 
length  of  the  slit  in  the  cardboard  inner  sole.  The  tongue  is  inserted  in  the  slit, 
and  the  bases  folded  back  and  cut  away  to  conform  to  the  front  of  the  inner 
sole.     When  removed  and  straightened  out  this  forms  the  pattern  in  Fig.  506. 


Pattern  of  paper  from  which  the  tin  is  cut.  The  edges  DD  and  CC  are  to 
be  turned  in.  Tin  is  folded  along  the  dotted  lines  AB — DC  and  DC  forming  the 
toe-post  in  Fig.  507. 

Fig.  507. 


Shows  the  toe-post  ready  to  be  inserted  into  the  cardboard  inner  sole. 
Rough  points  on  the  upper  and  under  surfaces  of  the  base,  which  are  made  by 
punching  holes  with  an  awl,  hold  the  toe-post  to  both  the  inner  sole  of  the  shoe 
and  the  cardboard  inner  sole. 

Fig.  508. 


Cardboard  inner  sole  with  toe-post  and  foot  adductor  attached.      (Sampson.) 

jected  to  pressure.     The  flap  of  skin  is  raised,  the  periosteum 
and  part  of  the  capsule  are  lifted  from  the  bone,  and  all  the  pro- 


776  OBTEOPEDIC  SUBGEBY. 

jecting  bone  is  removed  with  a  chisel,  so  that  the  surface  is  made 
perfectly  smooth.  Contracted  tissues  that  resist  a  corrected 
position  of  the  toe  are  stretched  or  divided,  and  the  wound  hav- 
ing been  closed  vdth  sutures  a  plaster  bandage  is  applied  about 
the  foot  and  toe.  This  may  be  worn  with  advantage  for  several 
weeks.  The  after-treatment  consists  in  the  use  of  a  proper  shoe 
and  daily  manual  adduction  of  the  toe,  in  order  to  retain  the 
improved  position. 

Cuneiform  osteotomy  of  the  metatarsal  bone  is  an  effective 
operation  if  the  base  of  the  wedge  includes  the  projecting  bone. 
Resection  with  chisel  or  Gigli  saw  of  the  head  of  the  metatarsal 
bone  is  the  most  effective  operation  if  the  deformity  is  extreme. 
It  should  not  be  employed  in  ordinary  cases,  as  the  removal  of 
the  head  of  the  bone  lessens  the  support  of  the  inner  border  of 
the  foot.  In  cases  of  resection  the  bursa  may  be  interposed 
between  the  extremity  of  the  metatarsal  bone  and  the  phalanx 
to  lessen  the  danger  of  anchylosis  as  suggested  by  Mayo. 

As  has  been  stated  hallux  valgus  is  often  combined  with  the 
weak  or  broken-down  arch  and  practically  always  by  a  depres- 
sion of  the  metatarsal  arch.  In  such  cases  the  foot  should  be 
supported  by  a  properly  fitted  brace.  This  is  of  special  im- 
portance after  treatment  by  operation. 

Bunion. — The  discomfort  of  hallux  valgTis  is  caused  in  great 
part  by  the  irritated  bursa  and  the  overlying  callus.  These 
symptoms  may  be  relieved  by  rest  and  by  hot  applications. 
Afterward  the  callus  or  corn  may  be  removed,  and  the  sensitive 
bursa  may  be  protected  by  a  bunion  plaster.  Operative  treat- 
ment should  be  deferred  until  after  the  acute  symptoms  have 
subsided. 

HAMMER^TOE. 

Hammer-toe  is  a  contraction  of  one  of  the  toes,  usually  of  the 
second,  in  which  the  first  phalanx  is  dorsiflexed,  the  second 
plantar  flexed,  while  the  third  may  be  flexed  or  extended.  The 
contracted  toe  is  overlapped  by  its  fellows;  its  projecting  dorsal 
surface  is  subjected  to  the  pressure  of  the  upper  leather  of  the 
shoe,  and  the  terminal  phalanx,  forced  against  the  sole  of  the 
shoe  and  compressed  by  the  adjoining  toes,  becomes  flattened 
into  a  club  or  hammer-like  form.  The  nail  is  distorted  and 
often  "  ingrown  "  ;  in  most  cases  a  corn  or  callus  forms  upon  the 
extremity  of  the  toe,  and  a  small  bursa  and  corn  over  the  pro- 
jecting knuckle  on  the  dorsal  surface.    A  third  corn  or  callus  is 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


177 


often  found  beneath  the  head  of  the  metatarsal  bone  which  has 
been  forced  downward  by  the  flexion  of  the  toe. 

Hammer-toe  is  usually  bilateral;  it  may  be  congenital  and 
even  hereditary,  but  it  is  usually  caused  by  shoes  that  are  too 
short  and  too  narrow.  The  second  toe  is  deformed  most  often, 
because  it  is  the  longest  and  because  it  suffers  most  from  the 
lateral  compression  as  well.  The  deformity  begins,  as  a  rule,  in 
early  childhood,  when,  the  growth  of  the  foot  being  rapid,  it  is 
more  likely  to  suffer  from  the  effects  of  outgrown  shoes,  and 
socks  as  well. 

Sjnnptoms.- — The  symptoms  are  practically  those  of  the  corns 
or  blisters  caused  by  the  pressure  of  the  shoe,  but  they  are  often 

Fig.  509. 


Hammer-toe,  hallux  valgus,  and  flat-foot. 

sufficiently  troublesome  to  interfere  seriously  not  only  with  the 
comfort,  but  with  the  ability  of  the  patient. 

Treatment. — The  resistance  to  the  rectification  of  the  de- 
formity is  caused  by  the  accommodative  changes  that  follow 
habitual  malposition.  In  cases  of  long  standing  all  the  tissues 
may  be  involved  in  the  contraction,  of  which  the  most  resistant 
are  the  shortened  capsular  and  lateral  ligaments  of  the  first 
interphalangeal  joint. 

The  congenital  hammer-toe  of  the  infant  may  be  treated  by 
daily  manipulation,  the  toe  being  held  in  proper  position  by 
narow  strips  of  adhesive  plaster  passed  over  and  under  it  and 
about  its  fellows.  In  older  children  a  digitation  in  the  stocking 
will  often  hold  the  toe  in  place  if  the  deformity  is  slight  and  if 
a  wide  shoe  is  worn.  In  adult  cases,  in  addition  to  the  manipu- 
lation and  shoe,  a  retention  apparatus,  in  the  form  of  a  light 
plantar  splint,  or  stiffened  inner  sole  to  which  the  toe  can  be 


778 


ORTHOPEDIC  SUBGEBY. 


attached,  should  be  worn.  If  the  deformity  is  more  resistant 
the  toe  may  be  straightened  by  force,  aided,  if  necessary,  by  the 
subcutaneous  division  of  the  contracted  ligaments ;  but  in  ordi- 
nary cases  the  only  effective  treatment  is  resection  of  the  joint. 
Sufficient  bone  should  be  removed  to  permit  the  correction  of 
the  deformity,  or,  in  case  of  its  recurrence,  to  prevent  the  pro- 
jection of  the  joint  above  its  fellows.  A  splint  of  celluloid  or 
other  material  should  be  worn  for  a  time.  By  this  operation 
permanent  relief  may  be  assured,  and  it  is  to  be  preferred  to  the 
mutilation  of  amputation. 

INGROWN  TOE-NAIL. 

The  figures  (Webb)  illustrate  an  effective  treatment  of  the 
milder  type  of  this  affection.     A  square  of  adhesive  plaster  is 


Fig.  510. 


Fig.  511. 


Fig.  512. 


Figure  1. 


Figure  2. 


Figure  3. 


placed  at  the  base  of  the  nail.  Twisted  silver  wire,  ISTo.  26,  is 
drawn  beneath  the  nail  and  is  fixed  in  position  by  adhesive 
strips.  If  all  pressure  is  removed  the  normal  relation  of  the 
nail  to  the  lateral  tissues  is  gradually  restored. 


OVERLAPPING  TOES. 

Overlapping  toes  are  very  common  among  adults,  owing  to 
the  pressure  of  the  narrow  shoe ;  and  not  infrequently  such  de- 
formity is  seen  in  infancy  of  apparently  congenital  origin. 
Deflected  or  deformed  toes  may  be  treated  in  infancy  by  manip- 
ulation and  by  support  with  strips  of  adhesive  plaster  in  the 
manner  described. 


DISABILITIES  AND  DEFOEMITIES  OF  THE  FOOT.         779 

In  .childhood  persistent  manual  correction  and  proper  shoes 

will  usually  overcome  acquired  deformity.     In  older  subjects  an 

inner  sole  somewhat  like  a  sandal,  to  which  the  toes  may  be 

attached  by  bands  of  tape,  may  be  employed  if  the  deformity  is 

considered  of  sufficient  importance  by  the  patient  to  demand 

treatment. 

EXOSTOSES  OF  THE  FOOT. 

Simple  exostoses  of  the  foot,  as  distinct  from  those  that  are 
incidental  to  disease,  as,  for  example,  to  osteoarthritis,  are,  in 
most  instances,  induced  by  pressure  upon  a  projecting  bone  of  a 
somewhat  deformed  foot.  The  common  examples  are  the  hyper- 
trophy of  the  navicular  (often  seen  in  weak  foot  of  young 
children),  the  projection  of  the  cuneiform  bones  on  the  dorsum 
of  the  hollow  or  contracted  foot,  the  thickening  of  the  internal 
condyle  of  the  first  metatarsal  bone  complicating  hallux  valgus, 
and  the  exostoses  on  the  posterior  aspect  of  the  os  calcis  in  achil- 
lobursitis  or  those  on  its  under  surface  that  may  be  induced  by, 
or  that  become  sensitive  to  pressure,  in  cases  of  gonorrhceal  in- 
fection and  the  like. 

As  a  rule,  the  treatment  of  the  deformity  of  the  foot  and  the 
removal  of  pressure  will  relieve  the  symptoms  without  other 
treatment.  Operative  removal  is  indicated  when  such  treat- 
ment is  not  effective. 

FRACTURE  OF  THE  METATARSAL  BONES. 

Fracture  of  a  metatarsal  bone,  most  often  the  second  or  the 
fifth,  may  occur  without  apparent  cause  other  than  walking. 
The  pain  and  the  subsequent  swelling  in  such  cases  may  be  in- 
explicable until  the  diagnosis  is  made  clear  by  an  X-ray  picture. 
The  accident  is  well  known  in  military  practice  as  an  incident 
of  marching. 

DISPLACEMENT  OF  THE  PERONEI  TENDONS. 

Permanent  displacement  of  these  tendons  forward  of  the  mal- 
leolus is  not  uncommon  as  a  result  of  paralytic  deformity,  par- 
ticularly talipes  calcaneus,  and  in  siTch  instances  it  gives  rise  to 
no  symptoms.  Displacement  of  one  or  both  of  the  tendons,  or 
rather  a  laxity  of  their  attachments  that  allows  an  occasional 
displacement  or  slipping  from  the  groove  behind  the  malleolus, 
may  result  in  serious  disability,  because  of  the  pain  that  follows 
the  displacement  and  because  of  the  weakness  and  insecurity  of 
which  the  patient  usually  complains. 


780  OETHOPEDIC  SUBGEBY. 

The  cause  of  tbe  laxity  of  the  tissues  that  allows  displacement 
in  feet  otherwise  normal  may  have  been  injury,  but  as  the  affec- 
tion is  often  bilateral,  the  predisposition  may  be  congenital. 

Treatment. — If  the  displacement  is  recent,  as  when  it  follows 
injury,  the  tendons  should  be  replaced,  and  the  foot  should  be 
fixed  in  a  plaster  bandage  until  repair  has  taken  place.  If,  as 
in  certain  instances,  dorsal  flexion  is  limited,  the  restriction 
should  be  overcome  before  the  bandage  is  applied.  If  the  dis- 
placement is  habitual,  a  brace  may  be  applied  to  restrain  those 
motions  at  the  ankle  that  induce  it.  In  cases  of  the  milder  type 
an  effectual  treatment  is  adhesive  plaster  strapping  so  applied 
as  to  prevent  dorsal  flexion  and  abduction  is  often  effective.  In 
chronic  cases  an  operation  with  the  aim  of  fixing  the  tendons  by 
suturing  the  displaced  sheath  in  its  normal  position  or  other- 
wise, may  be  indicated.  If  on  examination  the  cause  of  the  dis- 
placement appears  to  be  a  shortening  of  the  tendon  it  may  be 
divided  and  lengthened  in  the  ordinary  manner. 

SHOES. 

The  shoe  as  a  factor  in  the  etiology  of  deformity  and  dis- 
ability has  been  mentioned  several  times  in  the  preceding  pages, 
but  it  is  a  subject  of  such  importance  that  it  deserves  especial 
consideration. 

The  object  of  the  shoe  is  to  cover  and  to  protect  the  foot ;  there- 
fore, the  one  should  correspond  to  the  shape  of  the  other.  If  the 
feet  are  placed  side  by  side  the  outline  and  the  imprint  of  the 
soles  will  correspond  to  the  accompanying  diagram  (Fig.  513). 
The  outline  demonstrates  the  actual  size  and  shape  of  the  ap- 
posed feet,  emphasized  by  enclosing  them  in  straight  lines. 
Thus,  each  foot  appears  to  be  somewhat  triangular,  being  broad 
at  the  front  and  narrow  at  the  heel.  The  imprint  shows  the  area 
of  bearing  surface,  and  owing  to  the  fact  that  but  a  small  por- 
tion of  the  arched  part  of  the  foot  rests  upon  the  ground  it  ap- 
pears to  be  twisted  inward.  The  sole  of  the  shoe,  if  it  is  to 
enclose  and  support  the  bearing  surface,  must  conform  to  this 
inward  turn.  It  must  be  straight  along  the  inner  border  to  fol- 
low the  normal  line  of  the  great  toe,  and  a  wide  outward  sweep 
will  be  necessary  in  order  to  include  the  outline  and  thus  avoid 
compression  of  the  outer  border  of  the  foot  (Fig.  514). 

This  demonstration  of  the  true  form  of  the  foot  is  almost  an 
indispensable  preliminary  to  an  intelligent  discussion  of  the 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT. 


781 


relative  merits  of  shoes,  and,  indeed,  it  is  somewhat  of  a  revela- 
tion to  those  who  have  thought  of  the  foot  only  as  it  has  been 
subordinated  to  the  arbitrary  and  conventional  standard  of  the 


Fig.  513. 


Fig.  514. 


Normal  feet. 


Proper  soles  for  normal  feet. 


shoemaker.     The  shoemaker's  foot,  to  which  lasts  conform,  is 
much  narrower  than  the  actual  foot ;  the  great  toe  is  not  a  power- 


FiG.  515. 


Fig.  516. 


Shoemaker's  feet. 


Shoemaker's  soles. 


ful  movable  member,  provided  with  active  muscles,  but  is  small 
and  turns  outward,  so  that  the  fore  foot  is  somewhat  pyramidal 
in  form  and  turns  upward  as  if  to  avoid  contact  with  the  o:round. 


782 


OETHOPEDIC   SVBGEEY. 


This  imagiuarv  foot,  drawn  after  the  shape  of  the  ordinary  last, 
appears  in  the  diagrams  (Figs.  515  and  516).  Upon  it  the  sole 
of  the  shoe  has  been  indicated,  to  contrast  it  with  the  shape  of 
that  necessary  to  include  the  outline  of  the  normal  foot.     The 


vSkiagram   of  a  foot  modelled  to  fit  the  shoe,  illustrating  the  etiology   of  hallux 

valgus. 


actual  foot  is  thus  compressed  laterally  by  the  shoe  until  the 
stretching  of  the  leather,  during  the  "  breaking-in "  process, 
allows  it  to  overhang  the  sole.  The  great  toe  is  forced  outward, 
and,  with  its  fellows,  is  compressed,  distorted,  and  lifted  off 
the  ground  by  the  rocker-shaped  sole  (Fig.  518).  Finally,  al- 
though in  the  foot  there  is  a  well-marked  metatarsal  arch  (con- 


DISABILITIES  AND  DEFOBMITIES  OF  THE  FOOT.         783 

vexity  upward),  tlie  sole  is  made  with  a  convexity  downward. 
Tiius  the  foot,  according  to  the  age  at  which  the  reshaping  proc- 
ess is  begun  and  the  constancy  of  the  application,  is  gradually 
changed  in  shape  and  altered  in  function  (Fig.  517). 

This  remodelling,  however,  is  often  accompanied  by  such  dis- 
comfort that  the  individual  rebels  and  wears  a  shoe  with  a  square 
toe,  which,  from  the  conventional  standpoint,  is  supposed  to 
show  a  meritorious  effort  to  follow  nature.  But  the  demonstra- 
tion of  the  actual  foot  makes  it  evident  that  it  is  a  properly 
shaped  sole  which  serves  as  a  support,  not  the  part  which  pro- 
jects beyond  the  foot,  that  is  of  importance.  If  the  shoe  with 
the  square  toe  is  wider,  and  straighter  on  the  inner  side  than 

Fig.  518.  Fig.  519. 


The   rocker  sole.  The  flat  sole. 

another  with  a  pointed  toe,  it  is  in  so  far  an  improvement.  But, 
as  a  matter  of  fact,  one  of  the  worst  types  of  shoe  owes  its 
popularity  to  the  square  toe. 

The  object  of  the  heel  is  to  make  walking  easier  by  inclining 
the  body  somewhat  forward.  The  high,  narrow  heel  is  an  inse- 
cure support,  which  induces  deformity  by  throwing  more  strain 
upon  the  forefoot  and  pushing  it  forward  into  the  narrowest 
part  of  the  shoe.  The  heel  is,  of  course,  unnecessary  in  child- 
hood, and  should  not  be  worn,  since  it  limits  the  necessity  for 
and  therefore  the  use  of  the  normal  range  of  motion  of  the  ankle- 
joint.  The  ordinary  shoe,  with  its  stiff  shank,  by  restricting 
the  functional  use  of  the  foot,  favors  awkwardness  and  im- 
proper attitudes.  It  compresses  the  toes,  and  is  directly  respon- 
sible for  corns,  bunions,  ingrown  toe-nails,  and  deformities,  and 
indirectly  causes  or  aggravates  nearly  every  weakness  to  which 
the  foot  is  liable.  This  assertion  does  not  need  support  of  argu- 
ment, since  in  some  degree  it  has  been  proved  by  the  personal 
experience  of  every  shoe  wearer. 

The  shape  of  the  proper  shoe  corresponding  to  the  undis- 
torted  foot  has  already  been  demonstrated  (Fig.  514).    The  sole 


784  ORTHOPEDIC  SUEGEBY. 

should  be  thick  enough  for  protection,  but  not  so  rigid  as  to 
limit  normal  motion;  it  should  follow  the  imprint  of  the  foot, 
projecting  somewhat  beyond  the  outline  of  the  toes;  it  should 
be  flat  from  end  to  end  and  from  side  to  side  (Fig.  519),  and 
the  upper  leather  should  be  cajDacious.  In  other  words,  the  front 
of  the  shoe  should  be  designed  to  permit  and  to  encourage  nor- 
mal functional  activity,  the  slight  adduction  of  the  great  toe, 
and  the  alternate  expansion  and  contraction  of  its  fellows,  as 
may  be  observed  in  the  barefoot  child.  The  heel  should  be 
broad  and  low  and  the  shank  should  be  narrow  so  that  the  upper 
leather  may  be  properly  fitted  to  the  arch.  It  should  not  be 
braced  or  stiffened  but  flexible.  Most  adult  feet  are  more  or 
less  deformed,  and,  ,therefore,  better  suited  by  an  improved  than 
by  a  perfect  shoe.  In  selecting  shoes,  the  breadth  of  sole,  the 
angle  of  outward  deviation  of  the  soles  when  the  two  are  placed 
side  by  side,  and  the  capacity  of  the  upper  leather  must  be  the 
determining  points. 

The  most  effective  work  for  reform  can  be  accomplished  by 
providing  proper  shoes  for  children  and  thus  preventing  de- 
formity. The  inspection  of  children's  feet  shows  that  atrophy 
and  compression  begin  at  a  very  early  age,  and  if  protection 
could  be  assured  during  the  period  of  rapid  growth,  serious  dis- 
tortion might  be  prevented. 

Socks. — Although  of  far  less  importance  than  the  shoes,  the 
socks  worn  by  children  deserve  special  mention  as  a  factor  in 
deformity,  since  they  are  often  too  short  and  too  narrow  and  are 
made  of  unyielding  material,  so  that  the  proper  action  of  the  toes 
is  restrained.  The  socks,  like  the  shoes,  should  be  rights  and 
lefts,  but  as  these  are  not  in  common  use  one  must  select  those 
sufficiently  large  and  of  a  yielding  texture. 


CHAPTER   XXII. 

DEFOEMITIES  OF   THE  FOOT. 
TALIPES. 

Ijst  the  preceding  chapters  the  disabilities  of  the  foot,  of  which 
the  symptoms  were  of  greater  importance  than  actual  deformity, 
have  been  described.  One  now  passes  to  the  consideration  of 
the  congenital  and  acquired  disabilities,  of  which  deformity  is 
the  most  noticeable  feature. 

Fig.  520. 


Paralytic  equinus.  Kecoveiy  from  paralysis,  but  deformity  persists. 

Distortions  of  the  foot  are,  practically,  fixed  positions  in 
normal  attitudes  or  what  are  exaggerations  of  normal  attitudes ; 
in  other  words,  the  ordinary  deformities  can  be  voluntarily 
simulated,  and  the  centres  of  motion,  at  which  the  foot  is  de- 
formed, are  the  centres  of  normal  motion.  If  the  foot  has  been 
fixed  in  the  abnormal  attitude  during  the  period  of  formation 
and  rapid  growth,  or  if  it  has  been  used  for  any  length  of  time 
50  785 


786  OETHOPEDIC  SUBGEEY. 

in  the  abnormal  position,  tlie  deformity  becomes  exaggerated 
beyond"  the  possibility  of  imitation,  'and  secondary  variations  in 
its  shape,  size,  and  nutrition  follow. 

The  deformities  of  the  foot  are  grouped  under  the  generic 
name  of  talipes,  derived  from  talus  (ankle)  and  pes  (foot), 
signifying,  therefore,  a  form  of  deformity  in  which  the  patient 
walks  upon  his  ankles.  Talipes  was  thus  originally  synonymous 
with  the  popular  term  club-foot,  but  at  the  present  time  it  is 
used  simply  as  a  prefix  to  the  descriptive  titles  of  the  different 
distortions,  while  club-foot  is  usually  applied  only  to  the  most 
common  of  the  congenital  deformities,  equinovarus,  in  which  the 
distorted  foot  is  club-like  in  form. 

Varieties. — There  are  four  siinple  varieties  of  the  distorted 
foot  or  talipes. 

1.  Talipes  Ecfuinus,  the  extended  or  plantar  flexed  foot.  In 
well-marked  cases  the  patient  walks  upon  the  heads  of  the 
metatarsal  bones,  an  attitude  that  suggested  the  name  equinus 
(horse-like). 

2.  Talipes  Calcaneus,  the  dorsiflexed  foot,  in  which  the  heel  is 
prominent,  and  which  alone  bears  the  weight  in  walking ;  hence, 
calcaneus,  from  calcaneum,  the  heel  bone. 

In  these  forms  the  centre  of  motion  is  at  the  ankle-joint. 
Under  the  terms  equinus  and  calcaneus  are  included  not  only 
the  cases  of  marked  deformity,  but  also  those  in  which  the  range 
of  dorsal  or  plantar  flexion  is  sufficiently  limited  to  interfere 
with  function,  even  though  the  change  in  the  contour  of  the  foot 
is  slight. 

3.  Talipes  Varus,  the  inverted  foot.  In  this  deformity  the  foot 
is  turned  in  or  adducted,  and  combined  with  the  inward  twist 
there  is  practically  always  a  corresponding  degree  of  inversion; 
that  is,  the  inner  border  of  the  sole  is  elevated  and  the  outer 
border  is  depressed,  so  that  the  weight  falls  to  the  outer  side  of 
the  centre  of  the  foot. 

4.  Talipes  Valgus,  the  everted  foot.  This  deformity  is  the 
reverse  of  varus.  The  foot  is  abducted  and  the  sole  is  everted, 
so  that  in  use  the  weight  falls  on  the  inner  border. 

In  these  forms  of  lateral  deformity  the  centres  of  motion  are 
at  the  mediotarsal  and  subastragaloid  joints. 

Compound  Deformities. — Simple  deformities,  in  which  the 
foot  is  persistently  extended  or  flexed,  or  turned  in  or  out,  are 
comparatively  uncommon.  More  often  they  are  combined  in 
varying  degree;  thus  the  overextended  or  the  overflexed  foot  is 


DEFORMITIES  OF  TEE  FOOT. 


787 


usually  twisted  inward  or  outward,  making  four  varieties  of 
compound  deformity : 

1.  Talipes  Equinovarus,  the  extended  and  inverted  foot. 

2.  Talipes  Equinovalgus,  the  extended  and  everted  foot. 

3.  Talipes  Calcaneovarus,  the  flexed  and  inverted  foot. 

4.  Talipes  Calcaneo valgus,  the  flexed  and  everted  foot. 

In  the  various  forms  of  talipes  the  arch  may  be  increased  or 
diminished  in  depth.     It  is,  for  example,  usually  increased  in 

Fig.  521. 


Congenital  calcaneus.     In  this  form    (simple  calcaneus)    the  arch   is  obliterated. 
In  the  acquired  form    (calcaneocavus)   it  is  increased. 

calcaneus  and  equinus,  and  it  is  usually  diminished  in  valgus ; 
but  this  secondary  or  subordinate  deformity  is  not  recognized 
in  the  ordinary  classification.  If  the  arch  of  the  foot  is  simply 
exaggerated,  the  condition  is  sometimes  called  pes  cavus ;  if  it  is 
lessened  or  lost,  it  is  called  pes  planus.  These  slight  degrees  of 
distortion,  in  which  the  functional  disability  is  usually  more 
important  than  the  deformity,  are  rarely  classed  as  forms  of 
talipes.  Simple  cavus,  the  hollow  or  contracted  foot,  and  pes 
planus,  one  of  the  forms  of  the  common  weak  or  flat-foot,  have 
been  described  elsewhere.     (Chapters  XX  and  XXI.) 


788 


ORTHOPEDIC  SUBGEBY. 


Etiology. — ^From  the  remedial  standpoint,  the  cause  of  the 
deformity  is  of  far  greater  importance  than  its  form.  Thus, 
one  divides  the  distortions  of  the  foot  into  two  groups : 

1.  The  Congenital  Form,  in  which  the  foot,  in  process  of  forma- 
tion, has  become  deformed  before  birth. 

2.  The  Acquired  Form,  in  which  the  foot,  perfect  at  birth,  has 
at  a  later  time  become  distorted. 

The  congenital  deformity  may  be  considered  simply  as  a 
twisted  foot,  of  which  the  component  parts,  although  distorted 
to  a  greater  or  less  degree,  are  capable  of  regaining  perfect  form 
and  function.     This  is  practically  true  of  the  great  majority  of 

Fig.  522. 


Congenital   valgus. 


cases,  although  there  are  cases  complicated  by  defective  forma- 
tion of  the  foot  or  leg,  or  by  paralysis ;  as,  for  example,  in  cer- 
tain forms  of  spina  bifida  or  other  congenital  defect  or  disease 
of  the  nervous  apparatus. 

The  acquired  deformity  is  nearly  always  a  consequence  of 
disease  of  the  spinal  cord  (anterior  poliomyelitis).  The  motive 
power  is  unbalanced  by  the  paralysis  of  certain  muscles  and 
distortion  is  induced  by  the  contraction  of  the  unopposed 
muscles  and  by  the  influence  of  gravity.  This  distortion  is 
confirmed  and  increased  by  the  accommodative  changes  in 
structure  that  accompany  functional  use  and  growth  in  the  ab- 
normal attitude. 

Far  less  often  acquired  talipes  is  the  result  of  paralysis  of 
cerebral  origin,  of  other  forms  of  disease  of  the  spinal  cord,  or 
of  local  paralysis  following  neuritis  or  injury  to  a  nerve  trunk. 


DEFORMITIES  OF  TEE  FOOT. 


789 


It  may  be  caused  by  scar  contraction,  as  after  a  severe  burn,  or 
by  direct  injury,  or  by  disease  that  may  interfere  with  subse- 
quent growth.  Such  are,  however,  extremely  uncommon  causes. 
Thus  it  is  evident  that  while  congenital  talipes  is   a  simple 


Fig.  523. 


■ 

^p 

1  -mi 

V  i 

■L.  r 

'N       1       g^ 

M^J[ 

ll 

iJ 

Congenital  club-hands  and  feet,  combined  with  anchylosis  of  nearly  all  the  joints. 
(.Compare  with  Fig.  524.) 


distortion  capable  of  perfect  cure,  acquired  talipes  though  easily 
corrected  can  not  be  cured  unless  recovery  from  the  original 
disease,  of  which  it  is  a  result,  has  taken  place. 

Etiology  of  Congenital  Talipes. — As  of  other  congenital  defor- 
mities, the  etiology  of  talipes  is  conjectural.  Occasionally  the 
influence  of  inheritance  is  apparent,  and,  again,  two  or  more 
children  with  club-foot  may  be  born  of  the  same  mother;  but, 
as  a  rule,  nothing  bearing  upon  the  deformity  appears  in  the 


790 


ORTHOPEDIC   SUBGEEY. 


family  or  personal  history.  The  most  reasonable  explanation 
as  applied  to  the  majority  of  cases  is  the  mechanical.  This  is, 
in  brief,  the  theory  that  the  foot  has  from  some  cause  remained 
for  a  longer  or  shorter  time  in  a  constrained  or  fixed  position, 
and  has  thus  grown  into  deformity. 

It  has  been  claimed  by  Eschricht^   and  also  by  Berg-^  that 
about  the  third  month  of  intrauterine  life  the  thighs  of  the 

Fig.  524. 


The   etiology   of   congenital    club-hands,    club-foot,    and   anchylosis    of  the   joints. 
The  attitude  at  birth.     Photograph  at  age  of  three  months.     (See  Fig.  523.) 

embryo  are  abducted,  flexed,  and  rotated  outward,  the  legs  are 
crossed,  and  the  feet  are  plantar  flexed  and  adducted,  so  that  the 
inner  surfaces  of  the  thighs,  the  tibial  borders  of  the  legs,  and 
the  plantar  surfaces  of  the  feet  are  held  in  close  apposition  to 
the  abdomen  and  to  the  pelvis  of  the  foetus.  Later  there  is  an 
inward  rotation  of  the  limbs,  the  feet  being  turned  gradually 
outward  until  the  soles  are  brought  into  contact  with  the  uterine 


'  Deutsche  Klinik,  18.51,  No.  44. 

^  Berg,  Archives  of  Medicine,  Xew  York,  December  1,  1882. 


DEFORMITIES  OF  THE  FOOT.  791 

wall,  the  feet  then  being  in  the  attitude  of  abduction  and  dorsal 
flexion.  According  to  this  theory,  there  is  a  regular  succession 
of  attitudes  during  intrauterine  life.  If  the  inward  rotation  of 
the  lower  extremity  is  prevented  or  if  it  is  incomplete,  the  foot, 
remaining  in  the  original  position,  becomes  deformed.  Thus 
equinovarus,  being  the  normal  attitude  of  the  early  and  middle 
period  of  intrauterine  life,  is  not  only  the  most  common,  but  it 
is  the  most  intractable  of  the  congenital  deformities.  But  if 
the  constraint  or  pressure  is  not  exerted  until  a  later  period, 
after  rotation  has  taken  j)lace,  when  the  foot  has  attained  or 
nearly  attained  its  normal  size  and  shape,  it  will  then  induce 
the  rarer  and  comparatively  slight  grades  of  deformity,  such  as 
calcaneus  or  valgus. 

This  theory,  which  seems  interesting  and  reasonable,  appears 
to  rest  on  a  very  insecure  basis.  Bessel  Hagen^  states  that  in 
embryos  of  30  mm.  in  length  the  foot  is  in  extreme  plantar 
flexion;  in  those  of  90  to  100  mm.  the  foot  is  at  a  right  angle  to 
the  leg;  and  from  this  size  to  that  at  full  term  the  foot  may  be 
found  in  any  position — abducted,  adducted,  or  dorsiflexed.  He 
states,  also,  that  inversion  is  not  the  usual  attitude  at  an  early 
period,  but  is  more  common  near  the  termination  of  intrauterine 
life,  and  when  it  is  present  it  is  more  often  combined  with  dorsi- 
flexion.  In  other  words,  there  is  no  time  when  the  foot  regu- 
larly and  normally  assumes  the  attitude  of  club-foot,  from  which 
it  is  changed  by  the  rotation  of  the  limbs.  Scudder,^  after 
similar  investigations,  arrived  at  practically  the  same  conclu- 
sions. He  states  that  there  is  no  necessary  relation  between  the 
age,  the  rotation  of  the  limbs,  and  the  position  of  the  feet. 

Whether  or  not  there  may  be  a  more  or  less  regular  change 
in  posture  during  foetal  life  it  is  evident  that  constraint  favors 
deformity.  If  the  constraint  is  slight,  and  if  its  influence  is 
exerted  at  a  late  period,  the  deformity  will  be  slight ;  if  it  per- 
sists from  an  early  period,  the  deformity  will  be  extreme  and 
resistant. 

One  of  the  causes  of  constraint,  and  thus  of  ultimate  deform- 
ity, appears  to  be  the  interlocking  of  the  feet.  Many  museum 
specimens  show  this,  and  in  some  of  the  cases  of  talipes  seen  dur- 
ing the  first  weeks  of  life  the  feet  may  be  replaced  in  the  atti- 
tude in  which  they  had  been  fixed  before  birth  (Fig.  337). 
Intrauterine  pressure,  although  not  usually  the  direct  cause  of 

^  Die  Pathologie  und  Therapie  des  Klumpfusses  Heidelberg,  1899. 
^Boston  Medical  and  Surgical  Journal,  October  27,  1887. 


792 


OETHOPEDIC  SVBGEFiT. 


club-foot,  undoubtedly  has  an  influence  in  aggravating  the 
deformity.  The  effect  of  pressure  is  not  infrequently  shown 
in  atrophic  areas  of  skin,  and  burs£e  even  are  sometimes  found 
over  prominent  bones. 

Entanglement  in  the  umbilical  cord,  the  direct  pressure  of 
intrauterine  or  extrauterine  tumors  and  the  like  may  be  men- 
tioned also  as  possible  causes. 

Evidence  of  restraint  and  of  abnormal  attitudes  of  the  limbs 
is  seen  not  infrequently  in  connection  with  club-foot;  for  ex- 

FiG.  525. 


Intrauterine  "  amputations."     The  patient  is  a  tailor. 


ample,  in  hyperextension  or  fixed  flexion  of  the  knees,  and  in 
cases  of  extreme  deformity,  the  foot  is  often  smaller  than  normal 
and  otherwise  asymmetrical. 

The  distorted  foot  may  be  imperfect  in  structure ;  toes  may 
be  absent,  "spontaneous  amputation"  (Fig.  525)  or  constrict- 
ing bands  about  the  leg  or  foot  may  be  present.  Such  abnor- 
malities are  usually  ascribed  to  amniotic  adhesions.  Talipes 
may  be  combined  with  evidences  of  impaired  or  arrested  devel- 
opment ;  with  harelip,  extrophy  of  the  bladder,  spina  bifida, 


DEFOEMITIES  OF  THE  FOOT.  793 

and  absence  of  patellae ;  or  with  other  deformities,  such  as  club- 
hand and  wryneck,  fixed  flexion  at  the  knees,  and  the  like ;  or 
there  may  be  evidence  of  intrauterine  disease,  as  in  anchylosis 
of  joints  (Fig.  523)  or  so-called  foetal  rickets.  Finally,  de- 
formities of  the  foot  may  be  accompanied  by  other  deformities 
and  malformations,  showing  evidently  an  abnormality  in  the 
original  make-up  of  the  germ.  This  latter  group,  which  in- 
cludes the  complications  of  club-foot  and  imperfection  of 
structure,  is  comparatively  small,  for,  as  has  been  already 
stated,  in  the  great  majority  of  cases  congenital  club-foot  is  a 
simple  deformity  capable  of  perfect  cure. 

Statistics. — The  most  accurate  statistics  are  those  compiled 
from  the  records  of  the  Hospital  for  Ruptured  and  Crippled,^ 
of  4T18  individual  cases  of  talipes.  Of  these  2103  were  con- 
genital and  2615  were  acquired.  The  relative  frequency  of  the 
congenital  and  acquired  forms  of  talipes  has  given  rise  to  much 
discussion  in  the  past,  and  statistics  on  this  point  are  at  con- 
siderable variance  with  one  another.  This  may  be  explained  by 
the  fact  that  acquired  talipes  is,  as  a  rule,  a  preventable  de- 
formity. At  the  present  time  the  extreme  degrees  of  acquired 
talipes  are  comparatively  rare,  and  the  deformity  is  usually  of 
a  much  slighter  grade  than  the  corresponding  form  of  congeni- 
tal distortion. 

Males.  Females.       Total. 

Sex  of  congenital  talipes 1355  748         2103 

Percentage 64.4  35.6 

Sex  of  acquired  talipes 1416  1199         2615 

Percentage    54.1  •   45.9 

Congenital  talipes  is  much  more  common  among  males  than 
among  females.  All  statistics  are  in  accord  upon  this  point. 
Acquired  talipes  is  more  equally  divided  between  the  sexes. 

Right.  Left.  Both.         Total. 

Foot  affected  in  congenital  talipes.      643  552  908         2103 

Percentage    30.4  26.1  43.5 

Unilateral  1195  =  57.5  per  cent.     Bilateral  918  =  43.5  per  cent. 

Right.  Left.          Both.  Total. 

Foot  affected  in  acquired  talipes.  .    1126  1102           387  2615 

Percentage 43  42.1  14.9 

Unilateral  2228  =  85.1  per  cent.     Bilateral  387  =:  14.9  per  cent. 

In  congenital  talipes  the  deformity  is  nearly  as  often  of  both 

as  of  one  foot,  while  in  the  acquired  form  unilateral  deformity 

^  W.  K.  Townsend,  A  Statistical  Paper  on  Club-foot.  Transactions  of  the 
Medical  Society  of  the  State  of  New  York,  1890.  These  statistics  have  been 
supplemented  for  me  by  Drs.  Waller  and  Weingarten. 


794 


OETEOPEDIC  SUEGEET. 


is  far  more  common.     In  each  variety  the  right  foot  appears  to 
be  more  often  affected  than  the  left. 


The  Relative  Frequency  of  the  Different  Forms  of  Co^'genital 

Talipes. 

Percentage. 
77.4 
6.8 
4.2 
4.1 
2.3 
2.2 
1.6 


Equinovarus     1629 

Valgus 144 

Varus    89 

Calcaneovalgus    87 

Equinus    49 

Calcaneus    47 

Equinovalgus  35 

Calcaneovarus    10 

Cavus    5 

Valgocavus 1 

Equinocavus     1 

Different  deformity  in  each  foot 54 


Eelative   Frequency   of   the    Different   Forms   of   Acquired    Talipes 
Together  with  the  Etiology. 


Spinal. 

Cerebral. 

Other 
foTms  of 
paralysis. 

Trau- 
matic. 

Total. 

Anterior 

polio- 
myelitis. 

Hemi- 
plegia. 

Para- 
plegia. 

Per  cent. 

Equinovarus 

Equinus 

Calcaneus 

Valgus 

Equinovalgus 

Calcaneovalgus 

Varus 

Calcaneovarus 

Equinocavus 

Calcaneovarus 

Cavus 

Varocavus 

610 

469 

313 

205 

163 

123 

68 

13 

38 

•    15 

48 

2 

59 

102 
7 
6 
1 
1 
8 
0 
0 
0 
1 
1 

41 
50 
3 
10 
5 
1 
3 
1 
0 
0 

1 
1 

18 

14 

9 

0 

1 
0 
0 

56 

43 

20 

37 

7 

15 

10 

0 

2 

1 

4 

0 

784 

678 

352 

259 

177 

141 

90 

15 

40 

17 

54 

4 

30 
25.9 
13.4 
9.9 
6.7 
5.4 
3.1 
0.5 
1.5 
0.6 
0.2 

Deformity  differ- 
ent on  each  side 

2067 

186 

116 

47 

195 

2611 

Anterior  poliomyelitis   2067  =:  79.9  per  cent. 

Cerebral    302  =  11.5  per  cent. 

Traumatic 195  =  7        per  cent. 

Comparative  Frequency   of   the  Different   Forms   of   Talipes,   Con- 
genital AND  Acquired. 

Congenital.  Acquired. 

Equinovarus    77.4  per  cent.  32.5  per  cent. 

Valgus    6.8  per  cent.  9.7  per  cent. 

Varus    4.2  per  cent.  2.7  per  cent. 

Calcaneovalgus   4.1  per  cent.  4.4  per  cent. 

Equinus    2.3  per  cent.  26.1  per  cent. 

Calcaneus     1.6  per  cent.  12.6  per  cent. 


DEFORMITIES  OF  THE  FOOT.  795 

It  will  be  noted  that  in  three-fourths  of  the  congenital  cases 
the  deformity  is  equinovarus,  and  that  equinus  and  calcaneus, 
rare  as  congenital  deformities,  comprise  more  than  one-third  of 
the  acquired  forms. 

Occasionally  the  deformity  is  different  in  each  foot,  far  more 
often  in  the  acquired  than  in  the  congenital  form  (147  of  the 
former,  or  30  per  cent.,  of  the  484  acquired  bilateral  deformities 
as  compared  with  54,  or  less  than  6  j)er  cent.,  of  the  bilateral 
congenital).  In  7  of  18  of  the  congenital  cases  the  deformity 
was  equinovarus  on  one  side,  calcaneus  on  the  other;  in  3, 
equinovarus  and  calcaneovalgus,  and  in  3,  simple  varus  and 
valgus.  In  congenital  cases  the  most  common  combination  is 
equinovarus  on  one  side  and  calcaneus  on  the  other,  iSText 
equinovarus  and  calcaneovalgus. 

In  31,  or  4  per  cent.,  of  735  cases  of  congenital  talipes  tabu- 
lated by  Waller  the  distortion  was  combined  with  other  con- 
genital defects  or  deformities,  viz.,  in  12  cases  with  double  club- 
hands ;  in  6  cases  with  defective  development  of  the  hands, 
webbed  fingers,  and  the  like ;  in  7  cases  with  spina  bifida ;  in  3 
cases  with  absence  of  one  or  more  bones  of  the  leg ;  in  1  case  with 
torticollis,  in  one  case  with  harelip ;  in  1  case  with  dislocation  of 
the  knee  and  anchylosis  of  an  elbow;  in  2  cases  with  general 
rigidity  and  deformity  of  the  joints. 

The  Anatomy  of  Congenital  Club-foot Talipes  Equinovarus. 

— Congenital  talipes  is,  in  the  great  majority  of  cases,  the  form 
in  which  the  foot  is  twisted  inward  and  downward,  so  that  in 
extreme  cases  it  resembles  the  club-like  extremity  that  has  re- 
ceived the  popular  name  of  club-foot.  The  ordinary  congenital 
club-foot  in  early  infancy  is  simply  a  foot  fixed  in  an  exag- 
gerated attitude  of  plantar  flexion,  adduction,  and  inversion. 
The  dorsum  of  the  foot  looks  forward  and  slightly  outward  and 
upward,  the  plantar  surface  is  abnormally  concave,  and  looks 
backward,  inward,  and  downward.  The  foot  often  seems  some- 
what smaller  than  normal,  and  the  heel  appears  to  be  ill-formed. 
Upon  the  outer  dorsal  surface  the  body  of  the  displaced  astrag- 
alus projects;  the  external  malleolus  is  prominent,  while  the 
internal  malleolus  lies  deep  beneath  the  redundant  tissues  of  the 
internal  aspect  of  the  foot. 

In  many  instances  the  turning  inward  of  the  foot  is  so  ex- 
treme that  it  conceals  the  equinus  element  of  the  deformity 
(Fig.  526).  Thus  equinovarus  is  often  classified  as  varus, 
especially  by  English  authors. 


796 


OETHOPEDIC   SUBGEEY. 


The  internal  structure  of  the  foot  corresponds  to  the  external 
contour;  thus  the  relation  of  the  bones  to  one  another,  and  even 
the  shape  of  the  individual  bones,  are  more  or  less  altered  as  the 
deformity  is  more  or  less  of  an  exaggeration  of  the  attitudes  that 
the  normal  foot  is  capable  of  assuming.  These  changes  are  most 
marked  in  the  astragalus  and  os  calcis. 


The  astragalus  is  thicker 


Fig.  526. 


Typical  congenital  equinovarus   (club-foot). 

at  its  external  than  at  its  internal  border,  or  somewhat  wedge- 
shaped  from  without  inward ;  it  is  plantar  flexed,  so  that  a  large 
part  of  its  body  protrudes  from  between  the  malleoli.  Its  neck 
is  often  somewhat  longer  than  normal,  and  it  is,  as  a  rule,  de- 
pressed and  deflected  inward  (rig.  527,  B).  The  os  calcis  is 
also  in  an  attitude  of  plantar  flexion ;  the  internal  tuberosity  is 
drawn  upward  to  the  vicinity  of  the  internal  malleolus,  its 
anterior  extremity  looks  downward  and  inward,  and  it  is  often 
bent  inward,  corresponding  to  the  deformity  of  the  neck  of  the 
astragalus.  Its  external  surface  looks  downward  and  forward, 
and  it  lies  directly  beneath  the  astragalus  instead  of  to  its  outer 
side,  as  in  the  normal  relation. 

The  navicular  is  drawn  inward  and  upward,  and  articulates 


DEFORMITIES  OF  THE  FOOT.  797 

with  the  inner  part  of  the  deflected  head  of  the  astragalus;  it 
lies  in  close  proximity  to  and  is  often  in  contact  with  the 
internal  malleolus ;  the  cuboid  is  displaced  upward  and  inward, 
and  lies  to  the  inner  side  of  the  anterior  extremity  of  the  os 
calcis.  The  remaining  bones  are  changed  in  position,  but  not 
materially  in  shape.  In  many  instances  the  tibia  is  rotated  in- 
ward upon  the  femur,  and  this  inward  rotation  of  the  leg  may 
persist  after  the  deformity  of  the  foot  has  been  corrected.  Less 
often  the  tibia  is  slightly  twisted  inward  on  its  long  axis.     In 

"Fig.  527. 


The  deformities  of  the  astragalus  in  club-foot :  A,  astragalus  of  a  normal 
infant ;  1,  from  above  ;  2,  from  within ;  3,  from  without.  B,  the  astragalus  in 
club-foot  in  the  same  position.      (Adams.) 

other  cases  there  is  often  a  moderate  degree  of  knock-knee  and 
laxity  of  the  ligaments  at  the  knee.  As  a  rule,  however,  these 
are  secondary  or  compensatory  effects  of  club-foot  that  do  not 
appear  until  the  child  begins  to  walk. 

The  ligaments  and  muscles  correspond  to  the  changed  rela- 
tions of  the  bones.  The  muscles  are  normal  as  to  their  struc- 
ture and  their  origin  and  insertion  but  those  attached  to  the  inner 
side,  the] extensor 'jand  adductor  group  are  shortened  and  are  "7^-*^ 
relatively  stronger  than  the  opposing  muscles  which  are  length- 
ened and  atrophied  from  disuse. 

To  sum  up :  all  the  component  parts  of  the  foot  participate  in 
the  deformity.  The  most  resistant  structures  of  the  deformed 
foot  are  the  plantar  fascia  and  the  ligaments  that  bind  the 
navicular,  the  os  calcis,  and  the  internal  malleolus  to  one 
another.  The  muscles  that  are  most  active  in  retaining  and 
increasing  the  deformity  are  the  tibialis  anticus,  the  tibialis 
posticus,  and  the  combined  gastrocnemius  and  soleus. 


798 


OBTHOPEDIC   SUSGEBY. 


Fig.  528. 


The  changes  that  have  been  outlined,  which  are  comparatively 
slight  and  which  may  be  easily  rectified  soon  after  birth,  become 
more  marked  as  the  part  develops;  and  when  the  child  begins 
to  walk  the  weight  of  the  body,  combined  vdth  grovd^h  and 
functional  use  in  the  abnormal  position,  increases  and  fixes  the 
deformity. 

In  the  adolescent  or  adult  type  of  club-foot  that  has  never 
been  treated,  the  deformity  is  so  extreme  that  the  patient  actu- 
ally appears  to  walk  on  the 
outside  of  his  ankles,  as 
the  term  talipes  implies. 
The  feet  turn  directly  in- 
ward, or  even  inward,  up- 
ward, and  backward,  and 
the  peculiar  walk,  by 
which  interference  of  in- 
verted feet  is  avoided,  has 
given  another  name  (reel 
foot)  to  the  deformity. 

In  such  cases  knock- 
knee  is  usually  well 
marked.  This,  although  it 
may  be  present  at  birth  is, 
as  has  been  stated,  usually 
a  secondary  distortion 
caused  in  great  part  by 
the  accommodation  to  the 
deformity;  that  is,  by  the 
diminution  of  the  base  of 
support  and  by  the  inter- 
ference of  the  feet  (Fig. 
531). 

The  legs  are  shrunken 
from  disuse.  Over  the 
outer  border  of  the  foot, 
in  the  neighborhood  of  the 
calcaneocuboid  articula- 
tion, there  is  a  large  cal- 
lus with  an  underlying  bursa.  The  foot  itself  is  atrophied  and 
is  smaller  than  the  normal.  The  changes  in  the  bones  are 
much  more  marked ;  only  a  small  part  of  the  articulating  sur- 
face of  the  astragalus  lies  between  the  malleoli,  and  this  pos- 


Talipes  equinovarus  in  adolescence,  ap- 
parently of  the  acquired  form,  showing  the 
displacement  of  the  astragalus  and  its  re- 
lation to  the  scaphoid,  also  the  atrophy 
and  distortion  of  the  bones  of  the  leg. 


DEFOBMITIES  OF  THE  FOOT. 


799 


terior  extremity  is  flattened  out  to  the  shape  of  a  wedge.  Thus, 
the  leg  bones  appear  to  be  displaced  backward,  a  change  most 
apparent  in  the  position  of  the  external  malleolus.  The  bones 
of  the  foot  are  more  or  less  atrophied,  and  the  normal  area 


Fig.  529. 


Fig.  530. 


Talipes  eguinovarus. 
The  tendons  on  the  front  of  the  foot.        Showing   the   tendons    in   the    sole    of 

the  foot   and  the   extreme  displacement 
of  the  OS  calcis. 


of  cartilage  has,  to  a  great  extent,  disappeared  from  the  articular 
surfaces  of  the  disused  joints. 

In  these  neglected  cases  the  foot  is  practically  a  simple  rigid 
support,  to  which  the  patient  has  been  so  long  accustomed  that 
he  may  walk  with  comparative  ease  and  with  no  discomfort 
other  than  that  caused  by  the  corns  and  bunions  at  the  pressure 
points. 

Sjmaptoms. — The  symptoms  of  congenital  club-foot  have  been, 


800  OBTHOPEDIC  SUBGEBY. 

to  all  intents,  included  in  the  description  of  the  deformity.  The 
functional  disability  is,  of  course,  considerable,  although  some 
patients  are  surprisingly  active  and  are  able  to  walk  long  dis- 
tances. As  the  discomfort  from  club-foot  is  due  almost  entirely 
to  the  corns  or  inflamed  bursse  over  the  bony  prominences,  its 
degree  depends,  of  course,  upon  the  use  to  which  the  foot  is 
subjected. 

Treatment. — In  considering  the  treatment  of  congenital  club- 
foot it  is  customary  to  divide  it  into  several  classes  correspond- 
ing to  the  degree  of  resistant  deformity. 

The  first  class  would  include  the  very  slight  or  non-resistant 
cases  in  which  the  deformity  may  be  almost  entirely  corrected 
by  slight  manual  force. 

The  second  class  comprises  those  cases  in  which  a  certain 
amount  of  varus  and  well-marked  equinus  persist,  which  it  is 
impossible  to  overcome  by  manipulation. 

The  first  and  second  classes  include  the  forms  of  infantile 
club-foot.  u^ 

The  third  class  comprises  the  cases  of  more  extreme  deformity 
and  those  in  which  the  resistance  to  the  correction  is  great  as  in 
many  of  the  cases  in  early  childhood  or  those  of  later  years  that 
have  been  inefficiently  treated. 

A  fourth  class  would  include  the  untreated  cases  in  the  adoles- 
cent or  adult. 

Congenital  club-foot  (talipes  equinovarus)  treated  at  the 
proper  time — that  is  to  say,  in  early  infancy  and  in  a  proper 
manner  in  a  great  majority  of  cases  may  be  perfectly  cured  both 
as  to  form  and  function. 

The  club-foot  in  childhood,  in  which  treatment  has  been  de- 
layed or  in  which  it  has  been  ineffective,  may  be  practically 
cured  but  a  certain  limitation  of  motion  and  more  or  less 
atrophy  of  the  foot  and  leg  persists  as  a  consequence  of  the  dis- 
use of  normal  function. 

Club-foot  in  the  adult  may  be  made  straight,  but  restoration 
of  perfect  function,  is  of  course,  impossible. 

Although  congenital  club-foot  is  an  eminently  curable  de- 
formity, yet  perfect  and  permanent  cure  requires  minute  atten- 
tion to  details  during  active  treatment,  supplemented  by  careful 
supervision  long  after  the  cure  is  supposed  to  be  complete.  'No 
other  deformity  presents  such  a  record  of  failures  and  incom- 
plete cures,  of  relapses  after  apparent  cure,  of  tedious  and  in- 
effective treatment  by  braces,  and  of  unnecessary  and  mutilat- 


DEFOBMITIES  OF  THE  FOOT.  801 

ing  operations.  Some  of  the  failures  may  be  explained  by 
neglect  or  by  want  of  opportunity.  A  few  are  due  to  the 
unusual  obstacles  in  the  deformity  itself,  but  by  far  the 
greater  number  must  be  accounted  for  by  failure  of  the  physician 
to  ap23rehend  the  true  nature  of  the  deformity  or  by  his  inex- 
perience in  the  practical  details  of  treatment. 

Principles  of  Treatment  of  Infantile  Club-foot. — The  infantile 
club-foot  is,  as  has  been  stated,  simply  a  twisted  foot.  It  is  true 
that  there  are  slight  changes  in  the  bones ;  but  the  bones  of  an 
infant's  foot  are  represented  by  yielding  cartilage,  which  will 
rapidly  reform  under  changed  conditions.  The  shortened  tis- 
sues may  be  easily  stretched  and  when  the  proper  relation  of  the 
bones  to  one  another  has  been  restored  the  joints  will  undergo 
an  accommodative  transformation  which  will  permit  normal 
movement. 

The  treatment  of  club-foot  may  be  divided  into  three  stages : 

1.  The  rectification  of  the  external  deformity. 

2.  The  support  of  the  foot  in  proper  position  during  the  proc- 
ess of  transformation  of  its  internal  structure  and  until  the 
normal  muscular  balance  has  been  regained, 

3.  The  period  of  supervision.  This  would  include  the  treat- 
ment of  possible  complicating  deformities  at  the  knee,  the  laxity 
of  ligaments  and  the  like,  as  well  as  the  oversight  of  the  func- 
tional use  of  the  foot  and  the  limb  during  the  early  years  of  life. 

The  normal  infant  moves  the  foot  in  various  directions,  in  a 
more  or  less  regular  alternation  of  postures,  but  the  motion  of 
the  club-foot  is  in  one  direction  only,  that  toward  which  the  foot 
is  turned.  The  muscles  on  the  back  and  inner  side  of  the  leg, 
which  are  alone  active,  become  relatively  irritable  and  hyper- 
trophied  as  compared  with  those  on  the  front  and  outer  side  that 
are  disused.  Thus  movement  of  the  deformed  foot  is  in  reality 
harmful,  because  it  increases  deformity  and  still  further  dis- 
turbs the  muscular  balance.  For  this  reason  the  temporary 
restraint  of  motion,  necessary  during  the  rectification  of  the  de- 
formity, may  be  considered  rather  of  advantage  than  otherwise. 
When  movement  is  again  permitted  it  must  be  in  the  directions 
opposed  to  the  deformity. 

The   First    Stage   of   Treatment.     Rectification   of   Deformity 

"  Rectification  of  deformity  "  must  not  be  mistaken  for  restora- 
tion of  symmetry,  a  misapprehension  to  which  the  majority  of 
failures  iii  treatment  may  be  ascribed.  It  means  that  when 
deformity  is  really  rectified  all  contracted  and  resistant  parts 
51 


802  ORTHOPEDIC   SUBGEBY. 

must  have  been  so  elongated  that  every  passive  motion  and  atti- 
tude possible  for  the  normal  foot  is  equally  possible  and  as 
easily  attained  in  that  which  was  deformed.  This  is  functional 
rectification  as  contrasted  with  the  simple  correction  of  de- 
formity. 

The  most  important  part  of  the  deformity  is  varus.  The 
foot  that  is  rolled  over  and  twisted .  inward  to  the  attitude  of 
extreme  inversion  (Fig.  526)  must  be  untwisted  and  placed  in 
an  attitude  of  extreme  abduction  or  valgus,  the  so-called  over- 
correction (Fig.  522).  Until  this  is  accomplished  no  attention 
whatever  need  be  paid  to  the  residual  equinus.  There  are  two 
reasons  for  this :  First,  that  the  attention  of  the  surgeon  may  be 
concentrated  on  one  and  the  most  important  part  of  the  de- 
formity; second,  because  by  this  preliminary  untwisting  the  os 
calcis  is  brought  into  the  upright  position,  into  its  proper  rela- 
tion to  the  astragalus,  to  the  bones  of  the  leg,  and  to  the  tendo 
Achillis,  so  that  the  true  degrees  of  equinus  may  be  appreciated. 

Preliminary  Manipulation, — As  a  rule,  the  second  or  third  week 
of  life  is  as  early  as  mechanical  treatment  can  be  undertaken. 
Until  then  preliminary  manipulation  by  the  nurse,  more  par- 
ticularly manual  straightening  of  the  deformity  by  gently  draw- 
ing the  foot  toward  abduction  and  retaining  it  in  the  improved 
position  for  a  few  minutes,  as  often  as  is  possible,  may  be  of 
service  in  overcoming  its  resistance.  As  a  treatment  by  itself, 
however,  simple  manual  correction  is  tedious  and  ineffective, 
although  partial  cures  have  been  attained  by  perseverance  in 
this  means  alone. 

Mechanical  Treatment. — This  is  the  treatment  of  choice  and 
routine  for  infantile  club-foot,  and  two  methods  may  be  de- 
scribed : 

1.  By  the  plaster  bandage. 

2.  By  some  form  of  simple  splint. 

The  principle  of  the  two  is  essentially  the  same.  The  foot  is 
drawn  toward  an  improved  position  and  retained  there  by  the 
plaster  bandage,  or  it  may  be  fixed  to  some  form  of  metal  splint 
or  brace  whose  shape  is  gradually  changed  from  week  to  week, 
as  the  resistance  lessens. 

Gradual    Rectification    of    Deformity    by    Means    of    the    Plaster 

Bandage. — In  this  treatment  care  should  be  taken  to  avoid  undue 
pressure,  irritation  of  the  skin,  or  insecurity  of  the  bandage. 
One  should  place  shreds  of  cotton  between  the  toes ;  and  the 
outer  aspect  of  the  ankle,  where  the  skin  is  thrown  into  folds 


DEFOBMITIES  OF  TEE  FOOT. 


803 


when  the  foot  is  straightened,  should  be  powdered  or  smeared 
with  vaseline.  A  thin  layer  of  cotton  is  wound  about  the  leg, 
just  below  the  knee,  in  order  to  protect  the  skin  from  the  hard 
margin  of  the  plaster  bandage,  and  a  similar  strip  is  carried 
about  the  toes.  The  foot  is  then  drawn  gently  toward  the  ab- 
ducted position  as  far  as  may  be  without  causing  discomfort. 
While  it  is  held  in  this  attitude  a  narrow  bandage,  preferably 
flannel  or  cotton  flannel,  is  smoothly  applied  to  the  leg  and  foot. 

Fig.  531. 


Neglected  club-foot,  showing  the  secondary  knock-knee. 


A  very  light  plaster  bandage  is  then  applied  from  the  ex- 
tremities of  the  toes  to  the  upper  part  of  the  leg.  The  turns  of 
both  the  plaster  and  the  flannel  bandage  should  be  made  from 
within,  downward  and  outward,  so  that  the  tension  aids  in  re- 
taining the  foot.  When  the  plaster  bandage,  which  during  the 
hardening  process  has  been  constantly  rubbed  and  manipulated 
so  that  it  may  fit  the  part  perfectly,  and  which  need  not  be 
thicker  than  blotting  paper,  has  become  firm,  a  long  stocking  is 
drawn  over  it  and  is  attached  to  the  body  clothing.  At  the  end 
of  a  week  the  bandage  is  removed.  The  leg  and  foot  are  gently 
bathed  with  alcohol,  thoroughly  dried,  powdered,  and  protected 
as  before,  and  the  bandage  is  again  applied.     At  this  second 


804  OETHOPEDIC   STJEGEEY. 

dressing  the  irritable  adducting  muscles,  after  the  interval  of 
complete  rest,  will  be  much  less  active  and  the  contracted  tissues 
will  be  less  resistant,  so  that  the  foot  may  be  in  many  instances 
easily  turned  somewhat  outward  or  beyond  the  line  of  the  leg. 
If  for  any  reason  the  support  does  not  hold  its  position  a  narrow 
^strip  of  adhesive  plaster  is  applied  to  the  outer  or  inner  surface 
of  the  leg,  its  lower  end  being  turned  back  and  incorporated  in 
the  plaster  bandage  which  is  then  fixed  in  position  by  direct 
adhesion  to  the  skin. 

After  four  or  five  applications  of  the  bandage,  at  weekly 
intervals,  the  foot,  in  ordinary  cases,  can  be  held  without  re- 
sistance in  the  attitude  of  extreme  eversion.  The  sole,  which  at 
first  looked  backward,  inward,  and  upward,  will  be  turned  in 
the  opposite  direction,  forward,  outward,  and  downward,  and 
the  inner  border  of  the  foot,  which  was  concave,  is  now  convex 
(Fig.  522).  When  the  varus  has  thus  been  overcorrected, 
treatment  is  directed  to  the  secondary  equinus  which  has  been 
already  partly  reduced.  At  first  one  carries  the  foot  upward 
(toward  dorsal  flexion),  while  it  is  still  retained  in  the  abducted 
position,  but  after  one  or  two  treatments,  when  the  right-angled 
attitude  has  been  attained,  it  is  brought  nearer  to  the  axis  of 
the  leg.  The  everted  position,  or  the  attitude  opposed  to  varus, 
is  retained,  however,  until  correction  is  completed.  In  correct- 
ing the  equinus  a  certain  amount  of  force  may  be  required, 
sufficient  to  cause  some  discomfort  during  the  application 
of  the  plaster,  but  not  sufficient  to  occasion  suffering  afterward. 
The  force  is  applied  to  the  entire  foot,  so  that  the  posterior 
extremity  of  the  os  calcis  may  be  drawn  downward  by  actual 
lengthening  of  the  tendo  Achillis,  and  not,  as  is  often  the  case, 
by  an  overcorrection  of  the  forefoot,  while  the  heel  remains  in 
its  original  position  of  plantar  flexion.  By  the  proper  applica- 
tion of  force  the  equinus  is  gradually  overcome ;  the  sharp 
indentation  or  fold  at  the  insertion  of  the  tendo  Achillis  is 
lessened,  and  the  heel  becomes  more  prominent. 

The  reduction  of  the  equinus  may  be  somewhat  more  difficult 
than  that  of  the  varus,  but  it  should  be  entirely  corrected  in  three 
or  four  months  from  the  time  of  beginning  the  treatment.  As 
has  been  stated,  correction  of  the  deformity  implies  overcorrec- 
tion (Fig.  521)  ;  and  it  is  well,  when  this  has  been  attained,  to 
hold  the  foot  for  several  weeks,  l\v  means  of  the  plaster  bandage, 
in  an  attitude  of  extreme  eversion  and  dorsal  flexion  (calcaneo- 


DEFORMITIES  OF  TEE  FOOT. 


805 


valgus)  in  order  to  impress,  as  it  were,  the  new  position  upon 
its  structure.  This  concludes  the  iirst  stage  of  the  treatment, 
the  simj)le  rectification  of  deformity. 

Correction  by  the  plaster  bandage  has  the  great  advantage 
of  placing  the  treatment  entirely  under  the  control  of  the  sur- 
geon. The  application  even  in  resistant  cases  should  at  most 
cause  but  temporary  discomfort   and  usually  none  whatever. 

Fig.  532. 


The  first  application  of  tlie  plaster  bandage,  showing  the  improved  position. 
(Compare  with  Fig.  526.) 


The  support  fits  perfectly:  it  is  light  and  clean,  and  it  holds  the 
foot  in  the  desired  attitude  without  undue  pressure. 

The  disadvantages  of  the  treatment  are  due  almost  entirely 
to  its  improper  application.  For  instance  too  much  force  may 
be  used  in  correction  or  the  bandage  may  be  too  tight  or  too 
heavy,  or  the  padding  may  be  so  thick  that  it  does  not  retain  its. 
position.  Excoriations  are  usually  due  to  carelessness  in  the 
application  of  the  bandage,  or  because  it  is  not  removed  in 
proper  season.  The  fear  of  compression  or  of  atrophy  of 
muscles  or  of  stunting  the  growth,  is  groundless.  At  the  end  of 
the  treatment,  the  corrected  foot  is,  as  a  rule,  larger  than  one 


806 


OBTHOPEDIC   SUEGERY. 


that  has  remained  untreated.  The  stunted  foot  is  the  result  of 
non-treatment,  or  of  ineffective  treatment  by  braces  or  other- 
wise; not  of  the  temporary  rest  necessitated  by  the  reduction 
of  deformity. 

The  Rectification  of  Deformity  by  Splints  and  Braces, — Of  me- 
chanical supports  there  are  many  varieties.  Complicated  ap- 
pliances should  be  avoided  because  they  are  unnecessary  and 
because  they  serve  to  distract  attention  from  the  rapid  and 
systematic  correction  of  deformity.  Of  the  simpler  braces  that 
used  by  Judson  is  oile  of  the  best  and  will  serve  as  a  type  to 
illustrate  this  form  of  treatment.     The  method  of  application 


Fig.  533.      Fig.  534 


— > 

c 


Fig.  535. 


Fig.  536. 


Fig.  537. 


Fig.  538. 


Fig.  539. 


Fig.  540. 


The  .Judson  club-foot  splint  and  its  application. 


may  be  described  in  Judson's  own  words :  "  The  apparatus 
which  I  have  conveniently  used  to  effect  this  reduction  before 
the  child  learns  to  stand  is  a  simple  retentive  brace  which  acts 
as  a  lever,  making  pressure  on  the  outer  side  of  the  foot  and 
ankle  at  A,  in  Figs.  533  to  536,  inclusive,  and  counterpressure 
at  two  points,  one  on  the  inner  side  of  the  leg  at  B,  and  the 
other  at  the  inner  Ijorder  of  the  foot  at  C.  It  is  advisable  to 
keep  in  mind  that  this  simple  instrument  is  a  lever,  because  if 
we  know  that  we  are  using  a  lever  with  its  three  well-defined 
points  of  pressure  we  can  make  the  apparatus  more  efficient 


DEFORMITIES  OF  THE  FOOT.  807 

than  if  we  view  it,  in  a  more  general  way,  as  an  apparatus  for 
giving  a  better  shape  to  the  foot. 

"  I  use  a  little  brace  made  of  sheet  brass,  doing  the  work  with 
a  few  simple  tools.  An  advantage  of  doing  the  work  one's  self 
is  that  there  is  no  room  for  doubt  as  to  where  the  blame  lies  if 
the  apparatus  does  not  work  well.  Two  curved  disks,  B  and  C, 
Figs.  535  and  536,  are  riveted  to  a  shank,  D,  and  thus  is  formed 
that  part  of  the  brace  which  applies  the  two  points  of  counter- 
pressure;  while,  on  the  other  hand,  the  point  of  pressure  is 
brought  into  action  bj  a  third  disk  or  shield,  Aj,  which  is  drawn 
tightly  against  the  outer  side  of  the  foot  and  ankle,  and  held  in 
place  by  a  strip  of  adhesive  ^Dlaster,  E,  which  includes  the  leg 
and  the  piece  which  connects  the  two  disks,  B  and  C.  The  disks 
are  lined  with  two  or  three  thicknesses  of  blanket,  easily  re- 
newed, when  necessary,  with  a  needle  and  thread.  These  braces 
are  so  cheap  and  easily  knocked  together  that  it  is  nothing  to 
apply  new  and  larger  ones,  using  heavier  material  for  the  shank 
as  the  child  grows.  In  general,  three  sizes  will  be  enough,  the 
shanks  being  12  gauge,  f  in.  wide;  14  gauge,  ^  in.  wide;  and 
16  gauge,  f  in.  wide.  The  disks  are  conveniently  made  from 
22  gauge,  1^  in.  wide.  The  rivets  are  copper  belt-rivets,  ISTo.  13. 
A  lip  turned  on  the  edges  of  the  disks,  with  the  flat  pliers,  gives 
stiffness  to  the  thin  brass  and  protects  the  skin  from  the  rough 
edge.  If  more  easily  obtained,  tin  disks,  light  bars  of  iron  or 
steel,  and  ordinary  iron  rivets  would  doubtless  answer. 

"  The  brace  is  applied  with  three  strips  of  adhesive  plaster. 
The  upper  and  lower  pieces,  E.  and  G,  Fig.  536,  are  simply  to 
keep  the  apparatus  in  place,  which  they  do  effectively  if  ordi- 
nary gum  plaster  is  used ;  while  by  drawing  the  middle  strip,  E, 
tightly  over  the  shield,  and  straightening  the  brace  from  time  to 
time,  the  deformity  is  gradually  and  gently  reduced.  At  each 
reapplication  the  brace  is  made  a  little  straighter  than  the  foot 
at  that  stage.  This  may  readily  be  done  by  the  hands,  and  then 
the  adhesive  strip  is  to  be  tightened  over  the  shield  until  the 
shape  of  the  foot  agrees  with  that  of  the  brace.  After  a  few 
days  the  brace  is  to  be  made  still  straighter  and  again  reapplied, 
and  made  tight  until  another  point  of  improvement  is  gained. 
The  brace  is  applied  very  crooked  at  the  beginning  of  treatment, 
as  in  Figs.  535  and  536,  and  is  straightened  from  time  to  time, 
and  a  longer  brace  ajDj^lied  as  the  deformity  is  reduced  and  the 
patient  grows. 


808  OBTHOPEDIC  SURGERY. 

"  By  this  simple  and  prosy  treatment,  carried  out  systematic- 
ally and  without  haste,  or  violence  or  pain,  the  foot,  unless  it  is 
a  frightful  exception,  may  with  certainty  he  changed  from  varus 
to  valgus.  At  the  same  time  the  tendo  Achillis  is  lengthened 
until  the  position  of  the  foot  is  near  the  normal,  or  at  right 
angles  with  the  leg,  as  the  result  of  manipulation  and  giving  the 
hrace  from  time  to  time  a  partly  anteroposterior  action.  Figs. 
535  and  536  show  approximately  the  shape  of  the  brace  at  the 
beginning  of  treatment;  Figs.  537  and  538  when  the  varus  is 
reduced,  and  Figs.  539  and  540  when  valgus  has  taken  the  place 
of  varus.  The  foot,  in  this  latter  stage,  may  not  hold  itself 
when  left  to  itself,  but  with  almost  no  force  and  with  one  finger 
it  may  be  pushed  into  valgus." 

When  the  varus  deformity  is  reduced  the  equinus  is  gradually 
corrected  by  carrying  the  splint  behind  the  internal  malleolus ; 
and,  finally,  if  necessary,  direct  upward  pressure  may  be  ap- 
plied by  lengthening  the  brace  and  applying  it  to  the  posterior 
aspect  of  the  foot  and  leg.  It  may  be  noted  that  manipulation 
and  stretching  the  contracted  parts  when  the  brace  is  removed 
is  of  much  importance  in  the  correction  of  deformity  by  this  or 
other  means.  Splints  of  wood,  tin,  felt,  and  the  like  may  be 
employed,  but  they  present  no  particular  advantage  over  that 
which  has  been  described. 

Tenotomy. — The  equinus  has  been  spoken  as  of  secondary  im- 
portance although  its  complete  correction  by  mechanical  means 
may  be  more  difficult  than  that  of  varus.  When  this  deformity 
is  especially  resistant  as  in  late  infancy,  time  will  be  gained, 
after  the  foot  has  been  forced  into  the  position  of  equinovalgus, 
by  the  division  of  the  tendo  Achillis.  This  is  the  most  resistant 
of  the  shortened  tissues,  but  even  after  its  division  it  may  be 
necessary  to  use  considerable  force  to  stretch  the  other  con- 
tracted parts  that  limit  extreme  dorsal  flexion.  Occasionally 
the  obstacle  seems  to  be  in  the  posterior  ligament  of  the  ankle, 
and  it  is  sometimes  of  service  to  reinsert  the  knife  and  to  divide 
this  structure,  in  part  at  least,  so  that  it  will  give  way  under 
manipulation.  When  the  foot  has  been  forced  into  the  position 
of  overcorrection  it  is  fixed  in.  a  plaster  bandage  for  several 
weeks,  until  the  interval  between  the  separated  ends  of  the  ten- 
don is  filled  in  with  the  new  tissue. 

In  some  instances  the  leg  is  rotated  inward  upon  the  thigh,, 
and  the  habitual  attitude  is  accompanied  by  accommodative 
changes  in  the  ligaments  of  the  knee-joint.     During  the  treat- 


DEFOBMITIES  OF  TEE  FOOT. 


ment  of  the  club-foot  this  secondary  distortion  may  be,  in  part 
at  least,  corrected  by  forcible  manual  rotation  of  the  leg  outward 
on  the  thigh  several  times  daily.  If  the  leg  is  slightly  bowed  it 
may  be  corrected  by  manijDulation. 

The  Second  Stage  of  Treatment.  Support  and  Restriction  of  Func- 
tion.— When  the  deformed  foot  has  been  corrected,  in  the  sense 
that  normal  movement  in  all  directions  is  no  longer  restricted, 
the  first  and  most  difficult  part  of  the  treatment  will  have  been 
completed.  But  although  the  foot  may  be  normal  in  appearance, 
its  muscular  balance  has  not  been  restored.  This  is  shown  by 
the  fact  that  when  support  is  removed  the  foot  usually  hangs 

Fig.  541. 


The  adhesive  plaster  support  as  used  after  correction  of  the  deformity. 


downward  and  inward,  and  there  is  little  apparent  power  in  the 
dorsiflexors  and  abductors  to  draw  it  upward  and  outward.  If 
at  this  stage  treatment  were  abandoned,  the  deformity  would 
inevitably  recur,  at  least  in  part.  For  this  reason  the 
foot  must  be  supported  in  proper  position  until  the  slack  of  the 
leng-thened  tissues  has  been  taken  up  by  development  in  the 
normal  attitude,  a  development  that  may  be  aided  by  massage 
and  other  forms  of  stimulation  of  the  muscles.  Practically, 
support  is  always  necessary  until  the  child  has  begun  to  walk. 
Retention  by  Adhesive  Plaster, — In  those  cases  of  the  milder 
type,  in  which  the  deformity  has  been  easily  and  quickly  cor- 
rected, temporary  support  only  is  indicated,  as  the  muscles 
generally  recover  activity,  and  for  this  purpose  adhesive  plaster 
will  often  serve.    A  narrow  strip  is  first  carried  about  the  fore- 


810 


OBTHOPEDIC   SUBGEBY. 


Fig.  542. 


foot,  to  it  a  longer  band  is  fixed  and  is  carried  up  the  outer  side 
of  the  leg  to  the  knee  where  it  is  held  in  place  bj  an  encircling 
band.  This  is  applied  with  sufficient  tension  to  hold  the  foot  in 
abduction  and  dorsal  flexion.  The  nurse  is  then  instructed  to 
push  the  foot  up  to  the  extreme  limit  many  times  during  the 
day.  She  is  taught  also  to  apply  the  dressing  properly.  This 
support  is  used  until  normal  motion  has  been  regained. 

The  Retention  Brace. — The  form  of  retention  brace  will  vary 
somewhat  according  to  the  indications  of  the  individual  case. 

The  object  is  to  hold  the  foot  in  what  is 
called  the  overcorrected  attitude — that 
is,  dorsiflexion  and  eversion.  This  may 
consist  of  a  calf-pad  and  foot-plate  with 
an  internal  flange  (Fig.  542)  of  alumi- 
num joined  to  one  another  by  a  thin 
steel  bar  shaped  to  the  heel.  The  brace 
is  held  in  place  by  adhesive  plaster.  One 
of  the  most  efficient  supports  for  older 
children  is  the  Taylor  brace  (Fig.  543). 
This  consists  essentially  of  a  light  up- 
right that  extends  along  the  inner  side 
of  the  leg  to  the  knee,  and  a  thin  steel 
foot-plate  of  the  exact  size  of  the  sole, 
with  an  upright  flange  on  the  inner 
side,  rising  to  a  point  just  above  the 
dorsal  surface  of  the  foot,  against  which  the  foot  is  pressed 
closely,  so  that  recurrence  of  the  varus  deformity  is  prevented. 
The  joint  at  the  ankle  is  provided  with  a  catch  that  prevents 
plantar  flexion,  but  permits  dorsiflexion.  By  bending  the  up- 
right and  the  sole  plate  the  foot  may  be  held  in  slight  ever- 
sion. The  apparatus  is  applied  with  straps,  as  illustrated,  and, 
if  necessary,  it  is  made  more  secure  by  a  band  of  adhesive 
plaster,  applied  on  the  inner  side  of  the  leg  to  hold  the  heel 
firmly  against  the  foot-plate.  The  foot  is  thus  held  constantly 
at  a  right  angle  to  the  leg,  or,  better,  in  the  early  stage  of  treat- 
ment, in  an  attitude  of  dorsiflexion  and  valgus. 

Occasionally,  after  complete  rectification  of  the  deformity, 
the  foot  still  turns  in.  In  most  instances  this  is  due  to  an 
inward  rotation  of  the  tibia  on  the  femur  at  the  knee-joint, 
but  in  some  cases  it  is  caused  by  a  spiral  twist  of  the  tibia  itself. 
In  order  to  correct  this  secondary  deformity  an  extension  of  the 
upright  of  the  brace  is  carried  beneath  the  leg,  provided  with  a 


A  retention  brace  used 
in  infancy. 


DEFORMITIES  OF  THE  FOOT. 


811 


joint  at  the  knee,  and  is  extended  np  the  outer  side  of  the  thigh. 
At  the  hip  it  is  attached  by  a  free  joint  to  a  padded  pelvic  band 
of  light  steel  (Fig.  554).     The  band  holds  the  upright  in  the 


Fig.  543. 


The  Taylor  club-foot  brace. 


Fig.  544. 


Taylor  club-foot  brace,  showing  the  method  of  application  and  attachment. 


812 


OETHOPEDIC  SUBGEEY. 


projjer  relation  to  the  thigh ;  thus,  by  twisting  the  part  below  the 
knee  the  foot  can  be  rotated  outward  to  the  desired  degTee.  In 
less  marked  cases  the  retention  bands  used  for  pigeon-toe  may 
be  employed  (Fig.  503), 

Methodical  Manual  Correction. — Several  times  during  the  day 
the  brace  should  be  removed  in  order  that  the  foot  may  be 
thoroughly  massaged  and  forcibly  turned,  first  toward  valgus — 
that  is,  outward  at  the  mediotarsal  joint — so  that  the  inner 
border  is  made  convex,  and  then  to  the  extreme  limit  of  dorsi- 
flexion  and  abduction.    If  the  leg  is  rotated  inward  it  is  forcibly 


Tig.  546. 


Fig.  547. 


The  Taylor  club-foot  bi-ace,  showing  the  adhesive  plaster,  by  means  of  which 
the  heel  is  held  down,  and  the  method  of  attachment.  This  brace  was  used  by 
Taylor  to  correct  deformity  as  well  as  to  retain  the  foot  in  p-roper  position,  as 
is  illustrated  by  these  figures.  As  a  retention  apparatus  the  foot-plate  should 
be  held  at  a  right  angle  to  the  upright  by  the  stop-joint  shown  in  Fig.  543. 

rotated  outward  on  the  femur.  Even  if  the  tibia  is  actually 
twisted  on  its  long  axis,  the  influence  of  the  brace  and  forcible 
manipulation  will  usually  correct  the  deformity.  Active  con- 
traction of  the  weak  muscles  may  be  induced  by  tickling  the  sole 
of  the  foot  or  by  the  use  of  electricity,  and,  finally,  the  entire 
limb  should  be  thoroughly  massaged  before  the  brace  is  re- 
applied. 

When  the  deformity  shows  no  tendency  to  recur  the  brace  may 
be  removed  for  a  part  of  the  day ;  later  it  is  used  only  at  night ; 


DEFORMITIES  OF  THE  FOOT.  813 

and,  finally,  it  may  be  discarded  if  the  child  walks  normally. 
But  it  is  best  to  continue  the  daily  manipulation,  more  particu- 
larly the  systematic  stretching  or  overcorrection  of  the  foot,  for 
a  long  time.  Thus  one  may  assure  one's  self  that  there  is  no 
tendency  toward  deformity,  of  which  the  first  symptom  is  always 
a  slight  limitation  of  dorsal  flexion  and  of  abduction. 

In  many  instances  the  deformity  may  have  been  so  thoroughly 
overcorrected  and  the  after-treatment  of  massage  and  stretching 
may  have  been  so  efficiently  applied  by  the  nurse  or  parent  dur- 
ing infancy,  that  the  retention  brace  may  be  unnecessary  when 
the  child  begins  to  walk.  On  the  other  hand,  the  inclination 
toward  deformity  may  be  sO'  marked  that  a  brace  may  be 
necessary  to  hold  the  foot  in  slight  abduction  and  valgus  for 
a  year  or  longer.  In  other  cases  the  use  of  a  light  brace  to 
hold  the  foot  in  the  overcorrected  position  during  the  night  is 
alone  required.  These  are  points  to  be  decided  by  the  circum- 
stances in  each  case.  The  period  of  observation  and  supervision 
is  included  in  the  final  stage  of  the  treatment. 

Third  Stage  of  Treatment.  Supervision. — During  this  period 
the  attitudes  of  the  limb  and  foot  of  the  walking  child  must  be 
carefully  watched,  and  particularly  the  signs  of  wear  on  the  sole 
of  the  shoe.  If  it  shows  greater  wear  on  the  outer  side  than  is 
usual  it  is  an  indication  that  the  weight  does  not  fall  directly  on 
the  centre  of  the  foot,  and  that  there  is,  therefore,  a  tendency 
toward  deformity.  This  must  be  counteracted  by  making  the 
sole  thicker  on  the  outer  side  or  slightly  wedge-shaped,  so  that 
the  weight  may  be  deflected  toward  the  inner  border. 

This  third  period  of  treatment,  or,  rather,  of  oversight  of  the 
functional  use  of  the  foot,  must  be  continued  indefinitely.  In 
fact,  it  is  the  quality  of  this  final  supervision  that  decides  in 
most  instances  whether  the  ultimate  outcome  is  to  be  what  is 
called  a  satisfactory  result  or  a  perfect  anatomical  and  func- 
tional cure. 

The  Treatment  of  Neglected  Club-foot. — The  treatment  of 
club-foot,  under  what  may  be  called  the  proper  conditions,  as 
outlined  in  the  preceding  pages,  applies  practically  to  all  cases 
before  the  completion  of  the  first  year  of  life,  and  mechanical 
rectification  may  be  successfully  employed  in  cases  far  beyond 
this  limit  of  age.  As  a  rule,  however,  when  the  patient  has 
walked  for  any  length  of  time,  the  resistance  of  the  tissues  has 
increased  to  such  an  extent  that  more  rapid  and  effective  treat- 
ment is  indicated.     The  investigations  of  Wolff  have  shown  that 


814  ORTHOPEDIC  SUEGEBY. 

the  internal  structure  of  the  bones  corresponds  to  their  external 
contour,  and  that  the  structure  and  contour  are  adaptations  to 
functional  use.  This  internal  structure  is  not,  however,  perma- 
nent, but  is  readily  transformed  to  conform  to  changes  of 
function.  If,  then,  the  external  contour  of  the  club-foot  were 
suddenly  reversed,  and  if  the  foot  were  used  in  this  new  attitude, 
a  transformation  of  the  internal  structure  of  the  tones  and  at 
the  same  time  of  their  shape  would  begin  at  once.  This  would 
continue  until  both  structure  and  shape  had  become  adapted  to 
habitual  function.  It  is  upon  this  natural  power  of  transforma- 
tion that  one  depends  for  the  final  and  complete  change  of  the 
distorted  bones  to  the  normal ;  and  what  is  true  of  a  resistant 
structure  like  bone  is  equally  true  of  the  other  constituents  of 
the  deformed  foot. 

Age  as  Influencing  Treatments — There  is,  then,  this  important 
difference  between  the  indications  for  treatment  in  infancy  and 
in  childhood.  In  the  first  instance  the  foot  has  no  essential 
function ;  in  the  second  the  weight  of  the  body  and  habitual  use 
tend  to  confirm  and  to  increase  the  deformity.  If  walking  is 
permitted  during  the  process  of  rectification  of  the  foot  it  must 
necessarily  retard  its  progress.  As  a  general  principle  of,  treat- 
ment, functional  use  should  not  be  permitted,  therefore,  until  the 
weight  of  the  body  may  aid  rather  than  retard  the  correction  of 
deformity.  The  complicated  and  cumbersome  machines  that 
are  described  in  the  older  text-books  were  designed  for  the  ambu- 
latory treatment  of  club-foot.  The  most  important  function  of 
the  brace,  aside  from  its  use  as  a  correcting  appliance  in  early 
infancy,  is  to  suj)port  the  foot  after  deformity  has  been  cor- 
rected and  to  guide  it  in  its  functional  use  until  its  normal 
strength  has  been  regained.  And  while  rectification  of  de- 
formity, even  in  adolescence,  by  simple  mechanical  means  alone 
is  possible,  yet  only  in  exceptional  cases  would  one  be  justified 
in  selecting  a  tedious  and  uncertain  treatment  which  offers 
practically  no  advantage  over  more  rapid  methods. 

The  Rapid  Correction  of  Deformity.- — The  principles  on  which 
operative  treatment  should  be  conducted  are  the  same  that  go'^- 
ern  mechanical  treatment.  Thus,  the  deformed  foot  must  be 
overcorrected,  and  it  must  be  fixed  in  the  overcorrected  position 
until  the  immediate  tendency  toward  deformity  has  been  over- 
come. It  must  then  be  supported  until  the  process  of  transfor- 
mation of  its  internal  structure  is  completed  and  until  the 
balance  of  muscular  power  has  been  regained.     Xo  surgical 


DEFOBMITIES  OF  TEE  FOOT. 


815 


operation,  however  radical,  can  be,  in  childhood  at  least,  cura- 
tive by  itself  alone.  Operative  procedures  are  undertaken 
simply  for  the  purpose  of  accomplishing  the  primary  overcor- 
rection, and  the  operation  by  which  this  object  can  be  attained 
with  the  least  interference  with  the  structure  of  the  foot  should 
be  selected.  Such  an  operation  is  what  may  be  called  forcible 
manual  corriction. 

Forcible  Manual  Correction, — The  patient  having  been  anes- 
thetized, one  first  attempts  to  correct  the  sharp  inward  twist  at 

Fig.  548. 


Reduction  of  the  varus  deformity.      (Lorenz.) 


the  mediotarsal  joint.  Supposing  the  left  foot  to  be  deformed, 
one  grasjDS  the  heel  with  the  right  hand  in  such  a  maimer  that 
the  jDrojection  or  muscular  part  of  the  palm  lies  on  the  outer 
aspect  of  the  foot  against  the  most  prominent  part  of  its  outer 
border,  which  is  at  the  junction  of  the  os  calcis  and  cuboid  bones. 
This  hand  serves  as  a  fulcrum  over  which  the  inverted  foot  may 
be  bent.  The  forefoot  is  then  grasped  firmly  by  the  left  hand, 
and  one  begins  a  series  of  outward  twists  over  the  fulcrum  of  the 
opposing  palm,  gently  at  first,  with  alternate  relaxation  of  pres- 
sure, but  with  gradually  increasing  force  as  the  resistant  tissues 
stretch  under  the  tension. 


816 


OBTHOPEDIC   SUEGEBY. 


If  greater  force  is  required,  a  triangular  block  of  wood,  well 
padded,  may  be  used  as  the  fulcrum  (Fig.  548),  one  hand  press- 
ing on  the  heel  and  the  other  on  the  forefoot ;  but  there  is  a  great 
advantage  in  using  nothing  but  the  hands,  because  one  feels  that 
no  injurious  force  is  likely  to  be  exerted.  Under  this  steady 
manipulation  the  foot  soon  loses  its  rigidity  and  its  elastic  recoil 
toward  deformity ;  it  becomes  so  limp  that  with  two  fingers  one 
can  not  only  hold  the  sole  straight,  but  can  push  it  or  bend  it 

Fig.  549. 


Fldttenmg  the  sole.      (Lorenz.^ 


outward.     This  completes  the  first  stage  of  the  methodical  cor- 
rection. 

One  then  turns  his  attention  to  the  inversion  of  the  sole,  which 
makes  the  outer  border  of  the  foot  lower  than  the  inner  border. 
The  leg  is  grasped  firmly  near  the  ankle  with  the  left  hand,  and 
with  the  right  the  foot  is  forcibly  twisted  in  a  direction  down- 
ward, outward,  and  upward,  over  and  over  again,  with  steadily 
increasing  force  as  the  tissues  slowly  yield,  until  it  may  be 
forced  into  a  position  of  extreme  abduction,  so  that  the  sole  may 
be  made  to  look  outward  and  downward — the  reverse  of  the 
former  attitude. 


DEFOEMITIES  OF  THE  FOOT. 


817 


One  next  stretches  the  contracted  plantar  fascia  and  reduces 
the  cavus  which  is  usually  present  by  forcing  the  forefoot  toward 
dorsiflexion,,  against  the  resistance  of  the  contracted  tendo  Achil- 
lis,  until  the  sole  is  made  perfectly  flat  (Fig.  549).  Finally, 
the  fourth,  and  often  the  most  difficult  part  of  the  rectification — 
that  of  forcing  the  displaced  astragalus  into  its  proper  position 
between  the  malleoli — is  attempted.  To  accomplish  this  the 
tendo  Achillis  is  first  divided  subcutaneously,  and,  if  necessary, 
the  posterior  ligament  of  the  aiikle  is  also  divided  at  the  same 

Fig.  550. 


Reduction  of  the  equinus  deformity.    (Lorenz.) 


time.  The  patient  is  then  turned  upon  his  face  so  that  with  the 
knee  resting  on  the  table  the  leg  is  held  upright.  This  allows 
one  to  hook  the  fingers  about  the  extremity  of  the  os  calcis,  while 
the  hand  and  arm,  lying  along  the  sole  of  the  foot,  may  be  used 
as  a  lever  to  force  it  toward  dorsal  flexion  as  the  os  calcis  is 
drawn  downward.  In  this  manner  forcible  stretching  is  con- 
tinued until  the  dorsum  of  the  foot  can  be  brought  almost  into 
apposition  with  the  crest  of  the  tibia.  When  the  operation  has 
been  completed  the  foot  should  be  perfectly  limp.  It  is  usually 
52 


818  OETHOPEDIC  SrSGEEY. 

someTvhat  congested  from  the  pressure  of  the  fingers,  but  it  is 
warm  and  the  circulation  is  unimpaired. 

One  may  assume  that  in  the  transformation  of  rigid  deformity 
to  yielding  tissues  that  can  be  moulded  into  the  desired  shape, 
the  component  parts  of  the  deformed  foot  must  have  been  sub- 
jected to  considerable  violence ;  that  ligaments  and  muscles  must 
have  been  stretched  and,  it  may  be,  ruptured :  that  new  surfaces 
are  now  apposed  to  one  another  in  the  articulations,  and  that  the 

Fig.  551. 


Untreated  club-foot,  showing  the  secondary  knock-knee.      (See  Fig.  552.) 

bones  have  been  forced  into  approximately  normal  position. 
This  method  of  treatment  has  a  g-reat  advantage  over  the  ordi- 
nary operative  treatment  in  that  the  entire  foot  participates  in 
the  correction  instead  of  a  limited  portion,  as  when,  for  example, 
bone  is  removed  by  cuneiform  osteotomy.  It  has  a  second  and 
almost  equally  important  advantage  in  that  the  immediate  use 
of  the  corrected  and  yielding  foot  is  possible  in  the  place  of  the 
necessary  rest  that  must  follow  cutting  operations.  For  these 
reasons  it  should  be  the  operation  of  choice,  and  preliminary, 
at  least,  to  more  severe  procedures  in  the  treatment  of  resistant 
club-foot  in  childhood.     The  only  disadvantage  of  the  operation 


DEFOBMITIES  OF  TEE  FOOT. 


819 


is  the  actual  labor  which  it  necessitates  on  the  part  of  the  sur- 
geon, usually  twenty  minutes  or  more  of  rather  exhausting  work. 
The  foot  must  now  be  fixed  by  a  plaster  bandage  in  an  over- 
corrected  position.  It  is  first  evenly  covered  with  a  layer  of 
cotton,  thick  bands  of  which  are  inserted  between  the  toes,  and 
while  it  is  held  by  the  assistant  in  the  overcorrected  position  the 
plaster  bandages  are  applied  from  the  tips  of  the  toes  to  the 


Fig.  552. 


Fig.  553. 


After    forcible    correction, 
with  Fig.    551. 


Compare  The     attitude     of     overcorrection  ,    in 

which  the  feet  are  fixed  after  the  opera- 
tive treatment,  the  plaster  bandage  ex- 
tending only  to  the  knees. 


upper  part  of  the  thigh.  It  is  important  that  the  toes  should 
not  project  beyond  the  bandage  because  of  the  swelling  that 
sometimes  follows.  It  is  important,  also,  that  the  foot  should 
be  held  in  the  proper  position  while  the  bandage  is  hardening, 
and  that  it  should  not  be  manipulated  to  any  extent  after  the 
bandage  is  applied,  in  order  that  no  rigid  wrinkle  may  press 
against  the  skin.  The  bandage  is  applied  above  the  knee  in 
order  that  the  tibia  may  be  rotated  outward  to  its  normal  posi- 
tion and  held  there,  and  because  more  eifective  fixation  may  be 
assured  and  greater  pressure  exerted  on  the  foot  in  walking. 


820  OFiTHOPEDIC   SUBGEEY. 

To  utilize  this  pressure  to  better  advantage  the  bandage  should 
be  made  very  thick  beneath  the  sole,  and  a  thin  foot-plate  of 
wood  mav  be  incorporated  in  the  plaster  if  due  care  is  taken  to 
prevent  pressure  on  sensitive  points.  When  the  bandage  is  ap- 
plied the  foot  should  be  flexed  beyond  the  right  angle,  twisted 
far  outward,  and  the  outer  border  should  be  elevated  consider- 
ably beyond  the  level  of  the  inner  border  (Fig.  552). 

One  would  suppose  that  much  pain  and  swelling  would  follow 
the  operation.  This  is.  however,  not  usually  the  case.  Often, 
on  the  following  day,  the  patients  are  able  to  stand  upon  the  foot, 
and  always  within  the  first  week  if  the  bandage  has  been  properly 
applied.  The  pain  following  this  operation  is  far  more  often 
caused  by  pressure  of  an  ill-fitting  bandage  than  by  the  violence 
that  has  been  used.  Thus  one  should  be  careful  to  remove  sec- 
tions of  the  bandage  if  it  appears  to  cause  undue  discomfort. 
These  points  are  usually  the  front  of  the  ankle,  the  back  of  the 
heel,  and  the  inner  border  of  the  great  toe. 

The  Importance  of  Functional  Use. — The  immediate  use  of  the 
foot  is  encouraged,  in  order  that  the  weight  of  the  body  falling 
on  its  yielding  structure  may  still  further  correct  the  deformity. 
Although  only  the  heel  and  inner  border  bear  weight  directly, 
yet  the  pressure  of  the  plaster  sole  on  the  parts  that  do  not  come 
in  contact  with  the  floor  is  usually  sufficient  to  mould  the  foot 
into  its  proper  shape.  If  gTeater  pressure  is  thought  to  be  neces- 
sary, wedges  of  wood  or  cork  may  be  attached  to  the  sole  of  the 
plaster. bandage,  so  that  all  parts  may  bear  weight  equally.  The 
bandage  is  covered  by  a  stocking ;  a  slipper  may  be  worn  in-doors 
and  an  ordinary  overshoe  for  street  wear. 

The  first  bandage  should  be  removed  at  the  end  of  about  four 
weeks,  as  it  will  have  Ijecome  loose.  The  foot  will  then  be  fonnd 
to  be  extremely  flexible,  and  by  an  enthusiast  it  might  be  con- 
sidered cured;  but  knowledge  of  its  previous  condition  should 
make  it  evident  that  a  much  longer  time  will  be  necessary  to 
allow  for  its  consolidation  in  the  new  position.  At  this  time 
almost  no  evidence  of  the  oj^eration  remains  except,  it  may  be, 
slight  discoloration  of  the  skin.  The  foot  is  again  held  as  far 
as  possible  in  the  overcorrected  position  and  another  plaster 
bandage  is  applied,  usually  as  far  as  the  knee  only.  This  re- 
mains for  from  six  weeks  to  six  months,  according  to  the  char- 
acter of  the  deformity  anel  quality  of  the  after-treatment,  it  be- 
ing apparent,  of  course,  that  the  longer  the  foot  is  fixed  in  the 
overcorrected  pe)sition  the  less  danger  of  subsequent  relapse. 


DEFOEMITIES  OF  TEE  FOOT. 


821 


Fig.  554. 


The  patient  uses  the  foot  constantly  and  is  drilled  in  the  proper 
method  of  walking,  so  that  the  muscles  of  the  limbs  may  become 
accustomed  to  the  new  and  normal  attitudes. 

In  most  instances  the  plaster  bandage  is  replaced,  at  the  end 
of  about  three  months,  by  a  brace  to  be  worn  inside  the  shoe, 
usually  of  the  simplest  description 
(Fig.  569),  consisting  of  an  up- 
right bar  with  a  calf  band,  either 
fixed  to  a  sole-plate  or  attached  by 
a  joint  that  will  permit  dorsal  flex- 
ion but  checks  extension  at  a  right 
angle.  This  is  applied  because 
the  dorsal  flexors,  after  years  of 
disuse,  only  slowly  recover  sufii- 
cient  power  to  resist  the  action  of 
the  opposing  group  and  the  in- 
-fluence  of  gravity. 

The  second  stage  of  the  treat- 
ment is  now  begun.  This  may  be 
divided  into  a  period  of  active 
treatment  and  one  of  supervision. 
The  first,  or  treatment-stage,  con- 
sists in  massage  of  the  entire  leg 
and  of  the  foot  to  stimulate  the 
growth  of  the  atrophied  muscles, 
and  methodical  manipulation  of 
the  foot  several  times  a  day.  The 
important  point  in  this  manipula- 
tion is  to  force  the  foot  with  the 
hand  to  the  extreme  limit  of  the 
range  of  motions  possible  imme- 
diately after  the  o]Deration,  viz., 
eversion,  abduction,  and  dorsal 
flexion,  in  the  same  order  as  at  the 
time  of  operation.     At  the  same 

time  the  patient  attempts  voluntarily  to  carry  out  these  motions 
with  his  own  muscles,  the  power  being  supplied  by  the  hand 
of  the  manipulator.  Slowly  the  muscles  gain  in  strength  and 
ability,  and  when  normal  muscular  power  and  balance  have 
been  regained,  the  patient  is  practically  cured.  But  for  a  long 
period,  supervision  of  the  patient's  attitude,  of  the  manner  of 
using  the  foot,  of  the  wear  of  the  sole  of  the  shoe  and  the  like 


El^^ 

H 

r 

y 

^^^^^K 

iiL^^ '--^^^^^^^1 

The  Taylor  club-foot  brace,  with 
pelvic  band,  to  prevent  inward 
rotation  of  the  leg.  The  brace 
is  shown  before  the  covering  and 
straps   are  applied. 


822  OBTHOPEDIC  SUBGEBY. 

must  be  exercised  if  one  aims  to  restore  its  normal  appearance 
and  function. 

One  cannot  exaggerate  the  importance  of  this  after-treatment, 
and  of  supervision  at  least  on  the  part  of  the  surgeon.  The 
active  treatment  may  often  be  left  to  the  parents.  But  constant 
oversight  is  necessary  to  make  this  after-treatment,  which  seems 
so  commonplace  and  simple,  effective,  and  to  assure  one's  self 
that  the  range  of  motion  regained  by  the  operation  does  not  grad- 
ually become  more  and  more  restricted,  even  though  the  contour 
of  the  foot  appears  to  be  normal.  Forcible  manual  correction 
may  be  employed  vs^ith  advantage  from  the  second  to  the  tenth 
year,  although  the  limits  may  be  extended  in  either  direction 
in  special  cases.  In  this  operation,  as  described,  the  tendo 
Achillis  is  the  only  structure  divided.  There  is  no  particular 
objection  to  subcutaneous  division  of  other  tendons  or  ligaments 
in  connection  with  forcible  manual  correction;  but  for  such 
prolonged  manipulation  it  is  much  better  if  the  skin,  which 
itself  must  be  stretched,  is  unbroken  and  dry  rather  than  moist 
from  the  bleeding  from  punctured  wounds.  For  this  reason  it 
is  well  to  correct  the  deformity  without  tenotomy  if  possible.-^ 
In  more  resistant  cases  overcorrection  may  require  two  or  more 
operations. 

Secondary  Deformities. — In  cases  such  as  have  been  described 
secondary  distortions  of  the  limb  are  often  present.  Knock-knee 
rarely  requires  other  treatment  than  daily  manual  correction 
in  connection  with  the  massage  of  the  foot  and  leg.  Hyper- 
extensioh  at  the  knee  will  correct  itself  during  the  treatment  of 
the  foot,  which,  being  fixed  in  an  attitude  of  dorsal  flexion, 
obliges  the  patient  to  bend  the  knee  habitually  in  walking.  In- 
ward rotation  of  the  leg  upon  the  thigh  is  often  present.  This 
may  be  overcome  by  methodical  manipulation  and  by  the  use  of 
a  brace  attached  to  a  pelvic  band  (Fig.  554). 

In  many  instances,  particularly  in  childhood  and  adolescence, 
the  patient  has  so  long  walked  with  exaggerated  outward  rota- 
tion of  the  femur  that  after  correction  of  the  deformity  no  in- 
ward rotation  of  the  foot  appears,  even  though  inward  rotation 
of  the  tibia  be  present.    In  other  cases  the  inward  rotation  of  the 

^  Forcible  manual  correction  appears  to  have  been  described  first  by  Delore. 
Lorenz  employs  the  method  supplemented  in  the  older  cases  by  the  use  of 
his  osteoclast,  to  the  exclusion,  practically,  of  all  other  treatment.  (Heilung 
des  Klumpfusses  durch  das  modellirende  Eedressemeut,  Wiener  Klinik,  No- 
vember, 1895.)  For  this  reason  it  is  sometimes  called  the  Lorenz  treatment. 
The  method  that  has  been  described  has  been  employed  by  the  author  for 
many  years. 


DEFORMITIES  OF  THE  FOOT.  823 

foot  is  caused  by  a  failure  to  completely  replace  the  astragalus 
between  the  malleoli.  Occasionally  the  tibia  is  actually  twisted 
on  its  long  axis,  so  that  an  osteotomy  may  be  required  in  order 
to  overcome  the  deformity. 

Malleotomy.. — In  confirmed  club-foot,  of  the  type  under  con- 
sideration, the  chief  obstacle  to  perfect  correction  is  often  the 
astragalus.  This  is  displaced  forward,  downward,  and  inward, 
only  the  posterior  portion  of  its  articulating  surface  being  con- 
tained between  the  malleoli.  Thus  the  space  between  the  two 
bones  may  have  become  insufficient  for  the  anterior  and  wider 
part  of  the  body  of  the  asd^ragalus.  In  such  cases,  even  after 
division  of  the  tendo  Achillis  and  the  posterior  ligament  of  the 
ankle,  dorsal  flexion  still  remains  restricted,  and  examination 
shows  that  the  astragalus  still  projects  as  before,  even  though  the 
foot  has  been  forced  into  a  position  of  apparent  dorsiflexion  and 
abduction.  This  apparent  correction  is  the  result  of  overcorrec- 
tion at  the  mediotarsal  joint,  of  outward  rotation  of  the  tibia 
upon  the  femur,  and  of  backward  displacement  of  the  fibula. 

In  such  instances  the  malleoli  may  be  separated  from  one 
another  by  dividing  the  ligaments  that  hold  them  in  apposition. 
A  straight  incision  about  an  inch  long  is  made  directly  over 
the  anterior  aspect  of  the  articulation,  the  ligaments  are  divided, 
and  by  inserting  a  thin  chisel  the  bones  are  pried  apart,  while 
the  astragalus  is  replaced  in  the  proper  position.  This  is  usually 
easy  if  the  restraining  tissues  on  the  posterior  part  of  the  ankle 
have  been  divided.  The  wound  is  then  closed  and  the  foot  held 
in  the  overcorrected  position  by  a  plaster  bandage.  Complete 
correction  of  the  varus  deformity  should,  of  course,  precede  this 
operation. 

It  might  seem  on  first  consideration  that  if  immediate  correc- 
tion of  deformity  can  be  accomplished  so  easily  in  the  confirmed 
cases  it  should  be  employed  even  in  infancy.  There  are,  how- 
ever, practical  reasons'  against  it:  First,  because  the  foot  is  so 
small  that  it  cannot  be  easily  manipulated ;  second,  because  even 
after  it  is  corrected  it  must  be  supported  until  the  child  begins 
to  walk ;  and  third,  because  the  foot  can  be  so  readily  straightened 
without  operation,  which,  even  of  so  slight  a  character,  is  some- 
times the  cause  of  much  anxiety  to  the  parents.  For  these  rea- 
sons, although  immediate  reduction  of  deformity  is  a  practicable 
operation,  it  is  usually  postponed  until  a  later  time.' 

Subcutaneous  Tenotomy. — The  division  of  tendons  and  other 
tissues  by  the  subcutaneous  method  has  been  mentioned  inci- 


824  OETROPEDIC  SUBGEEY. 

dentallv,  but  as  it  has  so  long  occupied  an  important  and  even  at 
one  time  the  most  important  place  in  the  treatment  of  club-foot, 
the  operation  and  its  effects  may  be  described  somewhat  in  detail. 

Tenotomy,  as  has  been  stated,  is  performed  for  the  purpose  of 
removing  an  obstacle  to  the  overcorrection  of  deformity.  In 
the  acquired  or  paralytic  form  of  talipes  one  or  more  shortened 
tendons  may  be  the  chief  obstacles  but  in  the  congenital  form, 
in  which  all  the  tissues  have  grown  into  deformity,  the  shortened 
tendons  are  by  no  means  the  only  resistant  parts,  and  tenotomy 
should  be  considered,  therefore,  merely  as  an  incident  in  cor- 
rection. In  the  ordinary  treatment  of  infantile  club-foot  ten- 
otomy is  usually  unnecessary  and  in  the  great  majority  of  cases 
division  of  the  tendo  Achillis  is  alone  required. 

When  the  tendon  has  been  divided  the  deformity  is  imme- 
diately overcorrected;  thus  the  two  extremities  are  separated  to 
the  extent  necessary  for  the  improved  position.  At  the  end  of 
three  weeks  or  more,  or  at  the  time  when  the  first  plaster  band- 
age is  removed,  the  space  will  be  filled  with  new  material,  and 
in  another  mouth  the  splice,  which  will  be  somewhat  larger  and 
thicker  than  the  normal,  should  be  strong  enough  for  use.  The 
slight  thickening  at  the  site  of  the  operation  may  persist  a  year 
or  more,  but  practically  the  new  and  lengthened  tendon  is  per- 
fectly normal,  as  is  the  function  of  the  muscle  of  which  it  is  a 
part. 

The  process  of  repair  is  somewhat  as  follows :  Immediately 
after  the  operation  the  space  between  the  divided  ends  of  the 
tendon  is  filled  or  partially  filled  with  blood;  then  leukocytes 
appear,  which,  with  those  in  the  blood  clot,  serve  as  pabulum 
for  the  plasma  cells  which  migrate  from  between  the  fasciculi  of 
the  tendon  and  from  the  tendon  sheath.  The  fibrin  and  red  cor- 
puscles of  the  clot  are  absorbed ;  the  extremities  of  the  divided 
tendon  soften  and  become  fused  with  the  new  material,  which 
begins  to  take  on  the  form  and  consistency  of  true  tendon  and 
to  separate  itself  from  the  adherent  sheath.  This  new  tendon 
differs  from  the  normal  structure  in  that  the  fibrous  fasciculi 
are  more  irreg-ular  and  its  substance  is  more  like  scar  tissue,  but 
practically  it  is  normal  in  its  appearance  and  function.^ 

Since  the  tendon  sheath  serves  an  important  purpose  in  re- 
pair, it  should  be  disturbed  as  little  as  possible.  For  this,  as 
well  as  for  other  obvious  reasons,  subcutaneous  tenotomy  of  the 
tendo  Achillis,  which  is  so  prominent  and  so  distinct  from  other 
^  R.  Seggel,  Beitrage  ziir  klin.  Chir.,  1903.  Band  xxxvii.,  S.  342. 


DEFOEMITIES  OF  THE  FOOT.  825 

important  parts,  is  to  be  preferred ;  but  if  more  extensive  divi- 
sion of  other  tendons  is  required  tie  open  operation  is  often 
indicated. 

Division  of  the  Tendo  Achillis. — For  this  operation  anaesthesia 
is  usually  required,  preferably  by  means  of  nitrous  oxide  gas ; 
and  it  is  hardly  necessary  to  state  that  surgical  cleanliness,  even 
in  so  slight  a  procedure,  is  essential. 

The  instrument  should  be  small  and  very  sharp,  so  that  no 
force  is  required  in  the  operation ;  the  blade  should  be  as  long  as 
the  tendon  is  wide.  The  patient  is  turned  upon  the  side  or  to 
the  prone  position,  so  that  the  foot  may  be  held  with  the  heel 
upward  by  the  left  hand.  The  position  and  size  of  the  tendon 
is  ascertained  by  careful  palpation,  and  the  knife  is  then  inserted 
to  its  inner  side,  at  about  the  level  of  the  extremity  of  the  in- 
ternal malleolus.  The  flat  surface  of  the  blade  is  held  parallel 
to  the  tendon,  and  it  is  passed  beneath  it  until  its  point  can  be 
felt  beneath  the  skin  on  the  opposite  side.  The  edge  is  then 
turned  upward  and  the  tendon,  being  made  tense,  is  divided  by 
a  sawing  motion  of  the  knife.  When  the  division  is  complete, 
as  indicated  by  the  separation  of  the  divided  ends,  the  knife  is 
withdrawn,  and  the  minute  opening  in  the  skin,  from  which 
there  is  usually  slight  bleeding,  is  covered  with  a  pledget  of 
aseptic  cotton.  The  foot  is  forced  into  dorsal  flexion  and  is 
securely  fixed  by  a  plaster  bandage.  In  applying  the  dressing 
one  should  take  care  that  no  pressure  is  brought  upon  the  seat 
of  operation,  as  this  might  interfere  with  the  effusion  of  plastic 
material.  As  soon  as  the  discomfort  attending  the  operation 
has  subsided  the  patient  is  encouraged  to  stand  and  to  walk. 
Functional  use  stimulates  the  circulation,  and,  far  from  retard- 
ing repair,  it  is  in  my  experience  an  important  agent  in  assur- 
ing firm  and  rapid  union. 

The  Open  Method.- — The  tendon  may  be  exposed  by  a  long 
vertical  incision;  it  is  then  split  for  a  distance  of  two  or  three 
inches,  and  the  division  is  completed  at  the  upper  and  lower 
ends.  The  two  halves  are  then  allowed  to  slide  by  one  another 
until  the  necessary  elongation  has  been  obtained.  These  are 
then  sutured  to  one  another. 

Theoretically,  this  operation,  which  assures  union  at  a  point 
of  selection,  is  safer  than  the  subcutaneous  method,  in  which  the 
ends  of  the  tendon  are  separated  from  one  another ;  practically^ 
it  is  in  this  class  of  cases  less  satisfactory  in  its  results  than  the 
subcutaneous  method. 


826  OETHOPEDIC   SUEGEEY. 

Division  of  the  pla-ntar  fascia  is  often  necessary.  The  ten- 
otome is  inserted  beneath  the  skin  at  about  the  centre  of  the  con- 
cavity to  one  or  the  other  side  of  the  central  band  of  the  fascia, 
which  is  divided  by  a  sawing  motion  of  the  knife.  The  part  is 
put  upon  the  stretch,  and  other  resisting  bands  to  the  outer  and 
inner  side  are  divided  in  the  same  manner;  the  cavus  is  then 
corrected  by  manual  or  instrumental  force. 

Division  of  the  tibialis  anticus  is  not  often  necessary,  as  this 
tendon  offers  little  resistance  to  the  rectification  of  deformity  of 
the  ordinary  type. 

The  tendon  of  the  tibialis  posticus  may  be  divided  together 
with  that  of  the  tibialis  anticus  near  the  points  of  attachment. 
If  the  operation  is  required  it  may  be  combined  with  simulta- 
neous section  of  the  calcaneonavicular  ligament,  with  which  are 
blended  the  anterior  part  of  the  deltoid  and  fibres  of  the  anterior 
ligament  of  the  ankle.  According  to  Parker's  directions,  the 
foot  should  be  strongly  abducted  to  make  the  parts  tense.  The 
tenotome  is  entered  directly  in  front  of  the  anterior  border  of 
the  internal  malleolus,  its  cutting  edge  being  turned  forward  be- 
tween the  skin  and  the  ligament.  It  is  then  turned  toward  the 
ligament,  and  the  tissues  are  divided  to  the  bone.  The  blade  is 
then  made  to  enter  the  interval  between  the  astragalus  and  the 
scaphoid,  and  is  carried  downward  and  forward  to  divide  the 
inferior  part  of  the  ligament  and  at  the  same  time  the  tendons 
of  the  tibialis  anticus  and  posticus. 

.  The  posterior  ligament  of  the  ankle-joint  may  be  divided  or 
sufficiently  weakened  so  that  it  may  be  ruptured  after  section  of 
the  tendo  Achillis  by  passing  the  knife  directly  downward  in  the 
middle  line  upon  the  upper  border  of  the  astragalus. 

The  Correction  of  Confirmed  Club-foot  by  the  Method  of  Juhus 
Wolff. — Wolff's  treatment  of  club-foot,  as  described  by  Freiberg, 
a  former  assistant  in  his  clinic,  may  be  summarized  as  follows  •} 
The  patient  is  ansesthetized,  and  with  the  hands  and  by  the  use 
of  a  moderate  amount  of  force  the  deformity  is  reduced  as  far  as 
possible.  The  foot  is  held  in  the  improved  position  by  means  of 
strips  of  adhesive  plaster  passing  from  the  dorsal  surface  of  the 
inner  border  of  the  foot  under  the  sole  and  up  to  the  outer  aspect 
of  the  leg.  The  leg  and  foot  are  then  covered  with  cotton  from 
the  tuberosity  of  the  tibia  to  the  tips  of  the  toes,  and  a  plaster 
bandage  is  applied.  As  the  plaster  is  hardening  the  position  of 
the  foot  is  still  further  improved  by  pressing  the  heel  inward 

^  Medical  News,  October  29,  1892. 


DEFOEMITIES  OF  THE  FOOT. 


827 


Fig.  555. 


and  the  forefoot  outward  and  upward.  Two  fenestra  are  cut  in 
the  plaster  at  the  points  of  greatest  pressure — one  over  the  ex- 
ternal surface  of  the  ankle  and  the  other  over  the  internal 
surface  of  the  great  toe.  If  tenotomy  is  considered  necessary  it 
is  usually  performed  as  a  jDi'eliminary  operation  several  days 
before  forcible  correction. 

On  the  third  or  fourth  day  after  the  operation  a  w^edge-shaped 
section  is  cut  from  the  bandage  on  the  outer  side  of  the  ankle- 
joint  and  a  linear  division  is  made  about 
the  ankle,  so  that  the  leg  and  the  foot  parts 
of  the  bandage  are  sej^arated  (Fig.  555). 
The  leg  being  held  firmly,  the  foot  is 
forced  outward  and  upward  to  the  extent 
that  the  wedge-shaped  opening  on  the  plas- 
ter will  allow,  and  the  two  sections  are 
then  united  by  a  covering  of  plaster  band- 
age. For  the  secondary  correction  anaes- 
thesia is  not  required.  At  intervals  of 
several  days  larger  wedges  are  removed, 
and  the  manipulation  is  repeated  until  the 
patient  stands  with  the  foot  in  a  satisfac- 
tory attitude ;  that  is,  in  pronation,  abduc- 
tion, and  dorsiflexion.  If  the  deformity  is 
extreme  the  bandage  may  be  reapplied  be- 
fore the  correction  is  completed  with  ad- 
vantage. One  should  take  care  that  the 
toes  are  not  compressed,  but  lie  on  the 
same  plane  in  normal  relation  to  one 
another. 

When  rectification  is  complete  the  plaster  bandage  is  covered 
with  strips  of  pine  shavings,  held  in  place  by  a  crinoline  band- 
age, and  painted  with  carpenter's  glue.  When  this  is  hardened 
the  whole  is  covered  with  a  thin  silicate  bandage ;  over  this  the 
shoe  is  fitted  and  the  patient  is  encouraged  to  walk.  This  form 
of  dressing  is  used  until  the  transformation  of  the  deformed 
parts  may  be  supposed  to  be  complete,  the  time  varying  with 
the  case,  from  a  few  months  to  a  year.  The  time  required  for 
the  primary  correction  is  from  a  week  to  a  month.  When  the 
bandage  is  finally  removed  massage  and  exercises  are  to  be 
employed.-^     Wolff's  treatment  is  an  efficient,  though  tedious, 

^  Ueber  die  Ursachen,  das  Wesen  und  die  Behandlung  des  Kluinpfusses. 
Julius  Wolff,  Berlin,  1905. 


The  points  at  which 
the  bandage  is  divided 
and  the  wedge  removed. 
(Freiberg.) 


828 


OETHOPEDIC   SUEGEET. 


means  of  correction.     It  may  be  more  conveniently  employed  in 
later  childhood  and  adolescence  than  at  an  earlier  age. 

Forcible  Correction  of  Deformity  by  Means  of  Osteoclasts  and 
Wrenches.- — In  place  of  manual  correction  greater  force  may  be 
employed  by  means  of  wrenches  or  osteoclasts  to  overcome  the 
deformity.  There  is  this  important  difference  betvireen  the  two 
procedures :  force  may  be  applied  by  the  hands  for  as  long  a  time 
as  is  necessary  without  fear  of  injury,  while  force  applied  by  a 


Fig.  556. 


Fig.  557. 


The  Thomas  wrench  as  used  in 
the   correction   of   club-foot. 


Resistant    club-foot    in    later    child- 
hood.     (See  Fig.  5.59.) 


machine  must  be  momentary  because  of  the  pressure  and  strain 
on  the  parts  where  the  leverage  is  exerted.  Manual  force  con- 
tinuously applied  may  be  supposed  to  stretch  the  resistant  parts, 
and  although  much  less  power  is  exerted  it  is  really  more  effec- 
tive than  the  sudden  and  momentary  force  of  the  wrench  or 
osteoclast,  because  it  may  be  continued  until  the  deformity  has 
been  overcorrected,  while  complete  correction  by  mean&  of  in- 
struments may  necessitate  several  operations. 


DEFOEMITIES  OF  THE  FOOT.  829 

The  Thomas  Method. — Of  instrnmental  correction  that  by 
means  of  the  Thomas  wrench  is  one  of  the  simplest  and  most 
efficient.  The  wrenching  may  or  may  not  be  preceded  by  ten- 
otomy, a  point  to  be  decided  by  the  resistance  of  the  parts.  As 
a  rule,  division  of  the  tendo  Achillis  alone  is  necessary.  The 
instrument  is  a  simple  heavy  monkey-wrench,  of  which  the  jaws 
have  been  replaced  by  two  strong  pins  slightly  bulbous  at  the 
ends  to  keep  the  covers  of  rubber  tubing  from  slipping  off. 

The  wrench  is  applied  to  the  inner  side  of  the  foot  and 
screwed  down  so  that  it  may  "bite"  and  hold  its  place  firmly, 
for  if  it  slips  it  is  likely  to  abrade  or  tear  the  skin;  then  with 
considerable  force  the  foot  is  twisted  outward  and  upward  (Fig. 
556).  The  "  keynote ''  of  the  operation  is  to  so  wrench  the  foot 
that  it  loses  its  elasticity  and  shows  no  tendency  to  recoil  toward 
deformity.  The  foot  is  then  j)laced  in  the  best  possible  position, 
and  is  retained  there  by  the  Thomas  foot  splint  or  by  a  plaster 
bandage.  In  certain  instances  one  may  complete  the  rectifica- 
tion at  one  operation,  but  this  is  not  usually  attempted,  the  pro- 
cedure being  repeated  at  intervals  of  a  few  days  until  the  de- 
formity has  been  overcorrected.  In  very  resistant  cases  eight  or 
ten  applications  of  force  may  be  necessary.  When  the  deformity 
has  been  rectified  the  foot  is  held  in  the  overcorrected  position 
for  several  weeks  by  the  splint  or  by  the  plaster  bandage. 

As  a  walking  appliance  a  simple  upright  of  iron  with  a  calf 
band  is  applied  to  the  inner  side  of  the  leg,  from  a  point  just 
below  the  knee  to  the  heel  of  the  shoe  into  which  it  is  inserted, 
as  is  the  Thomas  knock-knee  brace  (Fig.  405).  By  bending  the 
upright  the  foot  may  be  held  in  slight  valgus,  and  this  position 
is  still  further  assured  by  making  the  outer  side  of  the  sole  of 
the  shoe  thicker  than  the  inner,  so  that  the  weight  falls  upon  the 
inner  border  of  the  foot.  In  many  instances  the  walking  brace 
may  be  dispensed  with  in  the  after-treatment,  but  a  light  brace 
is  usually  worn  to  hold  the  foot  in  the  corrected  position  during 
the  night,  until  the  power  of  the  abductors  and  dorsal  flexors  has 
been  regained.  Massage  and  manipulation  are  used  in  the  after- 
treatment  in  the  manner  already  described. 

When  properly  applied  the  treatment  is  satisfactory  and  free 
from  danger.  Sloughing  of  the  tissues  caused  by  the  pressure 
of  the  instrument  or  by  the  plaster  bandages  has  been  reported, 
but  such  accidents  have  not  occurred  in  the  extensive  practice  of 
Thomas  and  Jones. 

CoEEECTiox  BY  Meaxs  OF  THE  OSTEOCLAST, — The  late  Mr. 


830 


OSTHOPEDIC  SUBGEBY. 


Grattan,  of  Cork,  used  the  osteoclast  that  goes  by  his  name  (Fig. 
409)  to  crush  and  to  overcorrect  resistant  club-foot.  The  opera- 
tion may  include  besides  the  correction  of  the  deformity  of  the 
foot  itself,  fracture  of  the  leg  above  the  malleolus,  to  turn  the 
foot  toward  valgus,  and  a  second  fracture  half-way  up  the  leg, 
to  overcome  the  inward  rotation  or  twist  of  the  tibia.  Mr. 
Grattan's  results  have  been  very  satisfactory.  Other  appliances 
constructed  on  somewhat  similar  principles  may  be  employed. 

Of  these  the  Lorenz  osteoclast^  and  the  Bradford^  lever  ap- 
paratus are  the  most  effective. 

The  Open  Incision  Comljined  with  Forcible  Rectification  of  De- 
formity.    Phelp's   Operation. — When  extensive   division  of  con- 

FiG.  558. 


Illustrating  the  correction  of  the  left  foot  by  Phelps'  operation. 

tracted  parts  is  indicated  the  open  incision  is  to  be  preferred 
because  of  the  opportunity  thus  offered  for  the  recognition  and 
for  intelligent  selection  of  structures  that  require  division  in  the 
final  correction  of  the  deformity. 

Phelp's  operation  is  essentially  simply  the  division  of  resistant 
parts  through  an  incision  on  the  inner  border  of  the  foot,  com- 
bined with  sufficient  force,  manual  or  instrumental,  to  overcor- 
rect the  deformity.  It  is  the  most  conservative  of  the  more 
radical  procedures,  and  by  it  even  the  most  severe  type  of  de- 

^  Wiener  Klinik,  November,  December,  1895. 
-  Bradford  and  Lovett,  2d  ed.,  p.  414. 


JDEFOEMITIES  OF  THE  FOOT. 


831 


formity  in  the  adult  can  be  corrected;  that  is  to  say,  the  de- 
formity may  be  overcome  and  a  serviceable  foot  may  be  assured 
to  the  patient.  Perfect  functional  cure  is  not  possible  when 
deformity  has  been  confirmed  by  many  years  of  neglect. 

The  steps  of  the  Phelps  operation  are  as  follows :  After 
proper  surgical  preparation  the  Esmarch  bandage  is  applied. 
The  tendo  Achillis  and  usually  the  posterior  ligaments  of  the 
ankle  are  divided  subcutaneously,  and  by  manual  or  instrumen- 
tal force  one  attempts  to  correct  the  plantar  flexion.    An  incision 

Fig.  559. 


The  left  foot   (Fig.  557)   corrected  by  Phelps"  operation  and  by  cuneiform  osteot- 
omy of  the  OS  calcis. 


is  then  made  on  the  inner  border  of  the  foot,  just  below  and  in 
front  of  the  internal  malleolus,  which  is  extended  directly  down- 
ward over  the  head  of  the  astragalus  to  include  the  inner  quarter 
of  the  sole.  Through  the  incision  all  resistant  parts  are  divided 
in  order,  as  stated  by  Phelps. 

1.  The  tibialis  posticus,   and  the  anticus  if  it  offers  re- 

sistance. 

2.  The  abductor  hallucis. 

3.  The  plantar  fascia. 


832  0BTE0P2DIC  SURGERY. 

4.  The  flexor  brevis  digitorum, 

5.  The. long  flexor  of  the  toes. 

6.  The  deltoid  ligament  in  all  its  branches. 

During  the  successive  division  of  the  tissues  repeated  attempts 
are  made  to  correct  the  foot,  and  only  those  structures  are 
divided  that  present  themselves  as  tense  and  resistant  tissues 
when  the  foot  is  forcibly  abducted. 

In  the  adult  type  of  club-foot  no  particular  eft'ort  is  made  to 
recognize  the  different  structures,  but  all  the  tissues  on  the  inner 
side  of  the  foot,  including  bloodvessels  and  nerves,  the  deep  liga- 
ments, and  occasionally  the  tendon  of  the  peroneus  longais 
muscle,  are  divided.  Even  then  it  is  necessary  to  apply  con- 
siderable force  to  correct  the  deformity.  In  certain  instances 
the  rectification  of  deformity  necessitates  osteotomy  of  the  neck 
of  the  astragalus  or  the  removal  of  a  cuneiform  section  from  the 
OS  calcis.  The  object  of  the  Phelps  operation  is,  by  division  of 
resistant  tissues  and  by  the  use  of  force,  to  overcorrect  the  de- 
formed foot  at  one  sitting,  and  as  much  force  and  as  extensive 
division  of  tissues  as  are  required  to  accomplish  this  object 
should  be  employed  by  the  operator. 

When  the  foot  can  be  held  in  the  desired  position  without 
resistance  the  wound  is  covered  with  Lister  protective,  the  foot 
and  leg  are  thickly  covered  with  gauze  and  cotton,  a  plaster 
bandage  is  applied,  and  the  limb  is  elevated.  The  large,  gaping 
wound  closes  by  granulation  in  from  one  to  three  months.  The 
first  bandage  is  usually  changed  at  the  end  of  one  or  two  weeks, 
and  the  patient  then  begins  to  bear  weight  on  the  foot. 

By  this  operation  the  foot,  even  in  severe  cases  in  adult  life, 
may  be  made  straight  in  appearance.  It  is  evident,  however, 
that  in  such  cases  the  correction  of  the  deformity  of  the  bones  is 
by  no  means  perfect,  for  the  forefoot  may  be  simply  twisted 
outward  and  upward,  while  the  astragalus  and  os  calcis  may 
remain  in  an  approximation  to  their  original  deformity.  The 
operation  is  most  satisfactory  in  those  cases  of  resistant  varus 
in  which  the  equinus  deformity  has  been  overcome.  After 
thorough  overcorrection  by  the  Phelps  operation  the  danger  of 
recurrence  of  deformity  in  the  adult  and  adolescent  type  of 
club-foot  is  not  great,  and  in  many  instances  support  other  than 
that  of  the  plaster  bandage  for  several  months  after  the  opera- 
tion may  be  unnecessary;  but  in  childho<3d  the  ordinary  pre- 
cautions in  after-treatment  to  prevent  relapse  will  be  necessary. 


DEFORMITIES  OF  TEE  FOOT.  833 

Operations  on  the  Bones. — Osteotomy  of  the  neck  of  the  as- 
tragalus, as  a  supplementary  part  of  the  operation  of  forcible 
correction,  has  been  mentioned.  In  certain  instances,  particu- 
larly in  the  adolescent  or  adult  type  of  deformity,  the  displaced 
astragalus  may  oifer  such  an  obstacle  to  correction  that  its  re- 

FiG.  560. 


Resistant  club-foot  in  later  childtiood.      (See  Fig.   561.) 

moval  is  indicated — an  operation  first  performed  by  Mr.  Lund, 
of  Manchester. 

Astragalectomy. — The  astragalus,  which  in  club-foot  is  dis- 
placed forward,  may  be  removed  easily  by  means  of  an  incision 
passing  over  its  most  prominent  part,  in  a  direction  forward 
and  downward  from  the  tip  of  the  external  malleolus,  between 
the  tendons  of  the  peroneus  brevis  and  tertius.  The  soft  parts 
are  drawn  aside,  the  ankle  and  astragalonavicular  joint  are 
opened,  and  the  attachments  to  the  navicular,  and,  as  far  as 
possible,  those  at  the  inner  and  outer  border,  are  divided.  The 
foot  is  then  adducted  so  that  the  head  of  the  bone  may  be 
seized  with  forceps  and  drawn  upward,  the  interosseous  liga- 
ment and  the  internal  lateral  ligament  having  been  divided 
53 


834 


OBTEOFEDIC  SUBGEBY. 


with  curved  scissors,  the  astragalus  is  removed.  If  after  re- 
moval of  the  astragalus  the  deformity  cannot  be  corrected,  it 
should  be  supplemented  by  cuneiform  osteotomy.  A  useful 
movable  foot  may  be  obtained  by  this  operation,  but  it  by  no 
means  assures  the  patient  from  recurrence  of  deformity.  It  is 
never  indicated  as  a  primary  operation,  in  childhood  at  least. 
The  varus  should  be  thoroughly  corrected  as  a  preliminary  pro- 
cedure, for  until  then  the  resistance  that  the  astragalus  offers 
to  dorsal  flexion  cannot  be  accurately  estimated  (Fig.  561). 


Fig.  561. 


Fig.  562. 


After  forcible  correction  and  astraga- 
lectomy.      (See  Fig.  560.) 


Partially       corrected      club-foot, 
showing  secondary  knock-knee. 


Cuneiform  Osteotomy. — The  removal  of  cuneiform  sections  of 
bone  from  the  outer  border  of  the  foot  is  sometimes  indicated 
when  the  deformity  is  of  long  standing,  but  the  operation  should 
be  secondary  to  other  methods  of  correction.  The  aim  should  be 
to  lengthen  the  contracted  and  shortened  tissues  on  the  inner 
border  of  the  foot  to  the  extent  required  for  reposition,  not  to 
remove  bone  to  accommodate  these  shortened  tissues.  If  this 
has  been  shown  to  be  impossible  by  ordinary  means,  then  re- 
moval of  bone  may  be  indicated ;  but  it  is  not  often  necessary  in 


DEFORMITIES  OF  THE  FOOT.  835 

childhood  or  even  in  adolescence.  If  sufficient  bone  is  cut  away 
from  the  adult  foot  to  permit  complete  correction  of  the  deform- 
ity, relapse  is  not  usual ;  but  in  childhood,  as  has  been  stated, 
no  operation  will  take  the  place  of  after-treatment. 

The  treatment  by  cuneiform  osteotomy  as  it  is  ordinarily  car- 
ried out  is  sufficiently  simple.  In  severe  cases  the  astragalus  is 
usually  removed,  and  a  wedge-shaped  section  of  bone  is  taken 
from  the  os  calcis,  cuboid,  and,  if  necessary,  it  may  include  the 
navicular  bone  also.  The  external  malleolus  may  be  removed  if 
it  interferes  with  reposition.  Preliminary  fasciotomies  and 
tenotomies  are  usually  performed,  but  those  who  favor  this 
method  of  treatment  rarely  use  force  in  reposition.  If  the  de- 
formity is  less  marked  the  astragalus  is  not  removed,  but  a  part 
of  its  body  and  neck  are  included  in  the  cuneiform  resection. 
The  foot  is  retained  in  proper  position  until  the  wounds  are 
closed;  then  plaster  bandages  are  employed  for  several  months. 
Braces  are  seldom  used  in  the  after-treatment. 

Secondary  Osteotomy. — In  certain  cases  of  relapsed  or  ineffec- 
tively treated  club-foot,  even  in  childhood,  deformity  of  the  os 
calcis  interferes  with  correction  of  the  foot.  In  such  instances 
the  removal  of  a  cuneiform  section  of  bone  from  the  anterior 
extremity,  may  be  of  service.  Osteotomy  of  the  tibia  may  be 
required  in  cases  of  persistent  inward  rotation. 

Simple  Mechanical  Rectification  of  Deformity  in  Walkings 
Children  and  in  Later  Years. — It  has  been  stated  that  simple 
mechanical  rectification  of  deformity  was  possible  even  in  adoles- 
cence, but  that  the  time  required  for  such  treatment,  usually 
extending  over  several  years,  as  a  rule,  excluded  it  from  con- 
sideration. 

The  simplest  mechanical  treatment  is  that  by  which  the  foot 
is  slowly  forced  from  equinovarus  into  equinovalgus  by  a  brace 
on  the  lever  principle,  which  is  at  first  shaped  to  the  deformity, 
and  is  then  gradually  straightened  as  the  resistance  diminishes. 
When  the  midpoint  has  been  passed  between  varus  and  valgus 
the  weight  of  the  body  aids  in  the  correction  of  the  remaining 
varus  and  equinus.  The  modification  of  the  Taylor  brace  used 
by  Judson,  an  advocate  of  pure  mechanics  in  the  treatment  o£ 
club-foot  will  serve  to  illustrate  the  type  of  apparatus  which^ 
with  slight  change,  may  be  employed  to  correct  or  to  support  the 
weakened  or  deformed  foot. 

The  brace  consists  of  an  upright,  a  flat,  tapering  bar  of  mild 
steel,  a  foot-plate  of  steel  from  18  to  16  gauge,  and  a  strong  calf 


p^TUi  JO  JBq  Snijad^:^  ':jb^  ■b  ':^qSijdii  he  jo  s^sisnoo  aoBjq  aqj, 

•;ooj  paiujojap  jo  pauasj^aAi 
^v[%  :;joddns  o%  lo  ^oajJOD  o^  p3i!o[dni9  aq  X-ein  'eSu^qo  ^qSi];s  q^iM. 
■'qoiqM  sn^^Bi-eddB  jo  Qd£%  dx{i  o;Bj:^sri[]^i  o:^  9Aj;es  him.  :^ooj-qnp 
JO  :^u;aui:jBaj[|  aq^  ui  sauiBqaaiu;  ajnd  jo  a^-eaoApB  jits  'uospn£  Xq 
pasn  aoBiq  JLOil^ej^  aq;  jo  uor^Boijipoiii  aqj;,  -sanmba  puB  siijba 
Sninreniaj:  aq^;  jo  uoipaijoo  aq:).  ui  spie  ^poq  aq:^.  jo  :^q§TaAi  aq; 
snSpA  puB  snjBA  uaaAipq  passed  naaq  seq  :).uTodpTUi  aq:).  uaqyW 
•saqsraiinip  aollB:^SIsaJ  aq:).  sb  paiia;qSiBj:)s  T^ipnpBjS  uaq:)  si  pitB 
'iC:}iuij;ojap  aq:)  o:)  pad^qs  :)sj;^  :)b  si  qaiqAi  'a[dionij:d  idA^i  aq;  no 
aoBjq  V  Xq  snSpAouinba  o:).nT  snjBAonmba  niojj  paoioj  7C[Ai.0];s  si 
:)ooj  aq:)  qoiqAV  ^Cq  i^e-q}  si  :)Ltain:)Baj::).  ];Boin'Bqoaui  :)sa|diuis  aqj] 

•nopBJapis 
-noo  niojj  :)T  papnpxa  'a[nj;  v  sb  'sjeaX!  ];Bj:aAas  jaAO  Siiipna:)xa 
XjIBriSTi  ':)iiaiii:)Bai:)  qons  joj  pajinbao:  auiij  aq:)  %bt{'].  :)nq  'aouao 
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o^dinis  :)Bq:)  pa:)B:).s  naaq  s^q  :)j— -sjisaj^  ja^Tsi  ui  pu'B  U8jp|iqo 
Smm-B/^  m  AiimiojQQ  jo  uoiiBO^i^^oaa  i'Boiu'Bi[oai\[  aidmig 

•uoi:)b:)oj:  pjBAVut  :)ua:)sisj:ad  jo  sasBO  ui  paiinbaj 
aq  jC-Bin  Biqi;  aq:)  jo  Xuio:)oa:)SQ  -aoiAjas  jo  aq  ^^bui  'X:)iDiaj;xa 
joij:a:)UB  aq:)  inojj  aiioq  jo  uoipas  lujojiauno  b  jo  [BAoniaj:  aq:) 
saoiiB:)sui  qons  uj  •:)ooj  aq:)  jo  uoi:)oaj:ioa  q:)iAV  saiajia:)!!!  sio];bd 
so  aq:)  jo  7C:)iinj:ojap  'pooqp^iqo  ui  iiaAa  ':)ooj-qnp  pa^Baj::)  iCpAi:) 
-oajjani  jo  pa3dB[aj  jo  sasBO  uiB^jao  uj — •iCuio:)oa:iso  Aj^puoaag 

•:)iiaia::)Baj:)-ja:)jB  aq:)  ui  pasn  niopyas  ajB  saoBjg; 
•sq:)noni  [BjaAas  joj  paXoydina  aj-B  saSBpnBq  ja:)SB[d  naq;  fpasop 
ajB  spnnoAi  aq:)  ];t:)nn  noT:)Tsod  jadojd  ni  paniBpj  si  :)ooj  aqj[ 
•noipasaj  nijojianno  aq;  ni  papnpni  aJB  5[oan  pnB  ^^poq  s;i  jo 
;jBd  B  ;nq  'paAoniai  ;on  si  snyB^BJ^SB  aq;  pasjJBni  ssay  si  iC;iniJOj 
-ap  aq;  jj  'nopisodaj  ni  aajoj  asn  iCpjBJ  ;nani;Baj;  jo  poq;ani 
siq;  JOABj  oqAv  asoq;  ;nq  'panuojjad  vCy^Biisn  ajB  sainio;ona; 
pnB  sainio;opsBj  ^CjBniniipjj;  -nopisodaj  q;iAi  sajajja;ni  ;i 
ji  paAoniaj  aq  X^Bin  snpayyBni  pnja^xa  aqj[  'os^b  anoq  JBynoiABn 
aq;  apnpni  i^Bin  ;i  ^.^jBssaoan  ji  'pnB  'pioqna  'sppo  so  aq;  mojj 
na^jB;  si  anoq  jo  noi;oas  padBqs-aSpaAi  b  pnB  'paAOinaj  iCyyBnsn 
SI  sn];BSBj;sB  aq;  sasBO  ajaAas  nj  -aydniis  iCy;naioij;ns  si  ;no  pau 
-JBO  i^yiJBnipjo  SI  ;i  SB  Xnio;oa;so  nijojianna  £c[  ;nani;Baj;  aqj^ 

•;nani;Baj;-ja;jB  jo  aoB|d  aq;  a5[B;  him.  noi;Bjado  on 
'pa;B;s  naaq  SBq  sb  'pooqpyiqo  ni  ;nq  fpnsn  ;on  si  asdBpj  'A^i 
-nijojap  aq;  jo  noi;oajjoo  a;a];dnioa  ;inijad  o;  ;ooj  ;pipB  aq;  niojj 
Xba^b  ;no  si  anoq  ;napij)ns  jj    'aanaDsappB  ni  naAa  jo  pooqpytqo 

§88  '100^  SHI  Ro  ssiiiwsossa 


DEFORMITIES  OF  TEE  FOOT. 


837 


overcorrect  the  deformity  at  as  early  a  period  of  life  as  is  pos- 
sible, and  as  quickly  as  possible.  The  object  of  overcorrection 
is  to  overcome  all  the  resistance  of  the  tissues  that  may  even  in 
the  slightest  degree  limit  the  normal  range  of  motion  in  any 
direction.  The  foot  must  be  fixed  in  the  overcorrected  position 
until  the  tendency  toward  deformity  is  overcome. 

It  must  be  supported  in  the  proper  relation  to  the  leg,  and 
at  a  right  angle  with  it,  until  the  muscular  balance  has  been 
re-established  by  stimulation  of  the  weaker  and  by  limitation  of 
the  activity  of  the  stronger  muscles,  and  until  transformation  of 
the  internal  structure  has  been  completed. 


Fig.  565. 


Fig.  566. 


Fig.  567. 


Showing  the  progressive  reduction  of  deformity.  Fig.  565  shows  the  ordi- 
nary attitude  of  the  neglected  club-foot  in  childhood  with  the  adjustment  of  the 
brace,  it  being  bent  to  accommodate  the  deformity.  Fig.  566  shows  additional 
details — an  upright  spur,  useful  in  holding  the  heel  and  for  the  attachment  of 
straps  ;  the  spur  of  sheet  brass  that  may  be  bent  over  the  great  toe  to  hold  it  in 
position.  Fig.  567  shows  other  details  in  the  method  of  attachment,  a  strip  of 
adhesive  plaster,-  with  two  tails  in  the  place  of  the  band  of  webbing.  This  aids 
in  fixing  the  heel.      (See  Figs.  568  and  569.) 


If  efficient  mechanical  treatment  is  applied  at  the  proper  time 
— that  is  to  say,  in  earliest  infancy — no  operation  other  than 
division  of  the  tendo  Achillis  will  be  required. 

If  the  deformity  is  not  corrected  or  is  but  partially  corrected 


838 


OETEOPEDIC  SUEGEBY. 


when  the  child  begins  to  walk,  some  form  of  operation  is,  as  a 
rule,  indicated ;  but  division  of  the  resistant  tissues  must  always 
be  combined  with  the  employment  of  sufficient  force  to  accom- 
plish the  desired  result,  viz.,  overcorrection  of  the  deformity. 
Forcible  manual  correction,  applied  in  the  manner  described,  is 
the  most  efficient  means  of  attaining  this  object.  ISo  instrument 
can  equal  the  hand.  The  force  that  can  be  applied  by  the  hand 
is  sufficient  for  the  correction  of  all  the  ordinary  cases  in  early 
childhood,  and,  in  combination  with  subcutaneous  division  of 
the  more  resistant  tendons  and  ligaments,  even  in  later  childhood 
and  adolescence. 

Fig.  568.  Fig.  569. 


Showing  the  progressive  reduction  of  deformity  and  illustrating  the  process 
of  changing  the  shape  of  the  brace  from  time  to  time  until  it  holds  the  foot  in 
valgus.     (See  Fig.  565.) 

Astragalectomy  and  cuneiform  osteotomy  are  never  indicated 
as  primary  operations,  but  one  or  the  other  or  both  maybe  neces- 
sary for  the  complete  rectification  of  the  deformity  when  other 
means  have  failed. 

Forcible  correction  by  the  Thomas  wrench  under  the  same 
conditions  is  an  efficient  treatment,  and  the  instrument  may  be 


DEFORMITIES  OF  THE  FOOT.  839 

used  to  supplement  manual  correction  in  resistance  cases,  but 
there  is  a  manifest  disadvantage  in  submitting  a  patient  to  a 
succession  of  wrenchings  as  was  the  Thomas  practice,  if  imme- 
diate overcorrection  can  be  attained  at  one  operation. 

The  Phelps  operation,  v^hich  combines  thorough  division  of 
the  resistant  parts  with  the  application  of  sufficient  force  to  over- 
correct  the  foot,  is  the  operation  of  selection  for  the  more  re- 
sistant cases  in  adolescence,  in  adult  life,  and  in  extremely  re- 
sistant cases  in  childhood. 

Complete  cure  of  deformity,  even  in  the  later  years  of  child- 
hood, is  possible  by  means  of  braces  alone,  but  such  treatment  is 
very  tedious.  It  requires  the  continuous  supervision  of  the 
skilled  orthopedist,  as  well  as  the  intelligent  and  persistent  co- 
operation of  the  parents.  The  results  are  in  no  way  superior  to 
those  attained  by  more  rapid  methods,  while  the  disadvantages 
of  long  continued  use  of  braces  are  sufficiently  obvious.  To  the 
popular  faith  in  braces  as  a  cure-all  of  deformity,  and  to  the 
unintelligent  use  of  braces,  may  be  ascribed  now,  as  in  former 
times,  the  greater  number  of  failures  in  treatment  of  this 
,  eminently  curable  deformity.  On  the  other  hand  the  belief,  so 
prevalent  among  physicians,  that  a  radical  operation,  if  it  does 
not  absolutely  assure  a  cure,  is,  at  least,  the  essential  part  of  the 
treatment  is  equally  fallacious. 

Rectification  of  deformity,  by  whatever  means,  simply  com- 
pletes the  first  stage  of  treatment.  Perfect  cure  can  only  be 
assured  by  attention  to  the  small  details  of  after-treatment,  by 
checking  the  slightest  impulse  toward  deformity,  and  by  guiding 
the  unbalanced  foot  toward  normal  functional  use. 

OTHER  VARIETIES  OF  CONGENITAL  TALIPES. 

Porms  of  congenital  distortion  of  the  foot  other  than  equino- 
varus  are  not  uncommon;  but,  as  a  rule,  these  deformities  are 
so  slight  and,  as  compared  to  equinovarus,  so  easily  remedied 
that  they  are  relatively  of  little  importance. 

Congenital  Talipes  Varus. — Eighty-nine  cases  of  simple  varus 
are  recorded  in  the  table  of  statistics  in  a  total  of  2103  congeni- 
tal deformities  of  the  foot. 

This  deformity  often  appears  to  be  an  incomplete  form  of 
equinovarus,  but  in  some  instances  there  is  simply  an  inward 
twist  of  the  forefoot  without  inversion  (Pig.  502).  In  some 
cases  of  this  character,  the  forefoot  is  apparently  drawn  inward 


840  ORTHOPEDIC  SUBGEBY. 

by  tlie  active  movement  of  the  great  toe,  which,  in  such  cases, 
seems  almost  prehensile.  (See  Pigeon-toe.)  In  the  more 
marked  form  the  foot  is  adducted  and  inverted,  and  the  tissues 
are  very  resistant. 

The  slight  grades  of  deformity  may  be  treated  by  simple 
manipulation,  and  if  distortion  persists  after  the  first  year  the 
shoe  v^ill,  as  a  rule,  correct  it.  The  more  marked  varieties  must 
be  treated  like  the  varus  deformity  of  ordinary  club-foot,  by 
braces  or  by  the  plaster  bandage,  until  the  varus  has  been  trans- 
formed into  valgus.  The  after-treatment  is  the  same  as  that  for 
ordinary  club-foot. 

Congenital  Talipes  Equinus. — This  is  a  rare  congenital  de- 
formity, about  half  as  common,  according  to  the  statistics,  as 
varus  (49  cases  in  2103).  The  term  equinus  implies  that  dorsal 
flexion  is  limited,  but  that  the  foot  is  not  deviated  to  one  or  the 
other  side  (toward  valgus  or  varus).  In  congenital  equinus  the 
deformity  is,  as  a  rule,  slight,  and  in  many  instances  it  may  be 
overcome  by  gentle  manual  force  applied  frequently.  In  the 
more  resistant  type  mechanical  correction  or  tenotomy,  followed 
by  overcorrection  and  support,  may  be  necessary. 

Congenital  Talipes  Calcaneus. — Congenital  calcaneus  is  com- 
paratively rare  (47  cases  in  2103).  As  a  rule,  the  heel  is 
prominent,  the  foot  is  habitually  dorsiflexed,  and  the  dorsum  can 
be  easily  brought  into  contact  mth  the  crest  of  the  tibia  (Fig. 
521).  The  exaggerated  cavus  that  is  usually  present  in  ac- 
quired calcaneus  is  absent.  Occasionally  the  deformity  is 
accomj)anied  by  hyperextension  of  the  knee ;  and  if,  in  many 
instances,  there  is  a  history  of  breech  presentation,  it  may  be 
inferred  that  the  attitude  before  birth  was  one  of  extreme  flexion 
of  the  thighs  upon  the  abdomen,  the  anterior  surfaces  of  the 
extended  legs  being  pressed  closely  to  the  ventral  surface  of  the 
body,  the  feet  being  fixed  in  an  attitude  of  dorsiflexion.  As  a 
rule,  the  deformity  is  slight,  and  the  resistance  of  the  tissues  on 
the  anterior  aspect  of  the  leg  can  be  easily  overcome  by  massage 
and  manipulation.  The  foot  should  be  gently  forced  toward 
plantar  flexion  several  times  in  the  day,  and  the  weak  muscles 
of  the  calf  should  be  stimulated  by  massage. 

Cure  may  be  hastened  by  the  use  of  some  simple  form  of  re- 
tention splint  to  hold  the  foot  in  plantar  flexion  until  the  pos- 
terior group  of  muscles  has  recovered  its  power.  Tenotomy  or 
other  operative  treatment  is  not  often  required. 

In  rare  instances  the  tibia  may  be  bent  slightly  backward, 


DEFORMITIES  OF  THE  FOOT. 


841 


thus  increasing  the  deformity.  In  such  cases  the  distortion  of 
the  bone  may  he  overcome  by  manipulation  and  by  apparatus. 
Congenital  Talipes  Valgus. — Congenital  valgus  (Fig.  522)  is 
somewhat  more  common  than  the  preceding  varieties  (144  in 
2103).  jSTot  infrequently  it  is  combined  v^ith  a  slight  degree  of 
calcaneus  or  equinus.  The  resistance  of  the  contracted  tissues 
is  not  great,  and  the  deformity  may  be  overcome,  in  most  cases, 
by  persistent  manipulation.  If  the  muscular  power  is  suffi- 
ciently unbalanced  to  warrant  it  the  foot  should  be  fixed  in  the 
overcorrected  position  (varus)  for  a  time. 

Fig.  570. 


Congenital   calcaneovalgiis. 

Congenital  valgus  is  one  form  of  what  is  known  as  weak 
ankle,  and  it  frequently  passes  unnoticed  until  the  child  begins 
to  walk.  If  at  that  time,  in  spite  of  massage,  the  muscles  appear 
weak  or  if  the  foot  inclines  outward  when  weight  is  borne  it  is 
well  to  make  the  sole  of  the  shoe  wedge-shaped,  the  thicker  part 
(one-quarter  of  an  inch)  on  the  inner  side.  In  more  persistent 
cases  a  brace  may  be  necessary,  as  described  in  the  treatment  of 
the  acquired  variety.     (See  Weak  Foot.) 

Talipes  Equinovalgns  is  less  common  (35  in  2103).  This 
must  be  treated  as  the  other  varieties  by  complete  overcorrection 
of  deformity,  manual  or  otherwise,  and  by  subsequent  massage 
and  support  if  necessary. 


842 


OETHOPEDIC  SUSGEEY. 


Calcaneovalgus  (87  in  2103),  Calcaneovarus  (10  in  2103), 
Equinocavus  (1  in  2103),  Valgocavus  (1  in  2103).  Cavus  (5  in 
2103),  are  extremely  rare,  as  indicated  by  the  statistics.  If 
treated  early  by  persistent  massage  supplemented  by  retention 
apparatus,  these,  as  well  as  nearly  all  slighter  grades  of  congeni- 
tal deformity,  may  be  corrected  and  cured  even  before  the  child 
begins  to  walk. 


CONGENITAL  DEFORMITIES  OF  THE  FOOT  ASSOCIATED 
WITH  DEFECTIVE  DEVELOPMENT. 

Talipes  Equinovalgus  Associated  with  Congenital  Absence  of 
the  Fibula. — This  is  a  rare  deformity,  but  the  most  common  of 
this  class.  The  foot  at  birth  is  usually  in  an  attitude  of  well- 
marked  and  resistant  equinovalgus.  The  leg  is  somewhat  shorter 
than  its  fellow,  and  the  tibia  is  often  bent  sharply  forward, 
sometimes  to  an  acute  angle,  at  a  point  somewhat  below  the 
.centre,  as  if  it  had  been  broken.  At  the  most  prominent  point 
the  skin  may  be  adherent  or  it  may  present  a  dimpled  appear- 
ance. In  some  instances  the  formation  of  the  foot  is  perfect, 
but  more  often  one  or  more  of  the  outer  toes,  with  the  corre- 
sponding metatarsal  bones,  are  absent  (Fig.  572). 

Fig.  571. 


Congenital  equinuvarus,  with  deformity  of  the  great  toes. 


DEFOBMITIES  OF  THE  FOOT. 


843 


Statistics. — Haudek  collected  from  the  literature  97  cases.  Of 
these  46  were  in  males,  21  were  in  females,  and  in  30  the  sex 
was  not  recorded.  In  67  (69  per  cent.)  there  was  total  absence 
of  the  fibula.     In  30  the  de- 


fect was  partial ;  of  the  lower 
extremity  of  the  fibula  in  17, 
of  the  upper  extremity  in  9, 
and  of  the  middle  in  2  cases. 
In  27  cases  both  fibulae  were 
absent  or  defective,  in  68  one 
only — the  right  in  31,  the 
left  in  25,  and  in  the  others 
the  side  was  not  recorded. 
In  61  cases  toes  were  lacking, 
and  in  these  cases  it  may  be 
inferred  that  the  correspond- 
ing metatarsal  bones  were  ab- 
sent also.  The  fourth  and 
fifth  toes  were  absent  in  27 
cases ;  the  little  toe  alone  was 
missing  in  15.  In  many  in- 
stances, as  is  usual  in  cases 
of  defective  development,  de- 
formity of  other  parts  was 
present ;  for  example,  in  17 
instances  the  patella  was  ab- 
sent or  undeveloped  and  in 
11  the  upper  extremities 
were  defective.-^ 

Etiology — The  cause  of  de- 
formity, associated  with  ab- 
sence of  bone,  may  be  either 
an  original  defect  in  the 
germ  or  it  may  be  due  to  in- 
terference with  its  develop- 
ment. In  some  instances 
amniotic  adhesions  may  be 
one  of  the  predisposing 
causes ;  the  sharp  bend  in  the 


Fig.  572. 


Defective  formation  of  the  lower  limb, 
with  absence  of  fibula.  At  the  age  of 
5  years,  the  difference  in  the  length  of 
the  limbs  was  4%  inches.  At  14  years 
the  defective  limb  was  7  inches  shorter, 
the  deficiency  being  equally  divided  be- 
tween the  tibia  and  the  femur. 


^  Cotton  and  Chute,  Boston  Medical  and  Surgical  Journal,  1898,  Nos.  8 
and  9  (128  cases).  Mazzitelli,  Arch.  Ortopedia,  1898,  F.  5.  Boinet,  Eevue 
d 'Orthopedic,  November,  1899.  Vide  also  Emil  Hain  (113  cases),  Archiv. 
Orthop.  Mechanieotherapie  und  Unfal  Chir.,  1903,  Bd.  i.,  H.  1. 


844  OFTHOPEDIC  SFEGEBY. 

tibia,  so  often  present,  may  be  due  to  the  lessened  resistance  of 
the  defective  part. 

Treatment. — The  indications  for  treatment  are  to  correct  the 
deformity  of  the  foot  in  the  nsnal  manner.  The  bend  in  the 
tibia  may  be  straightened  by  manipulation  and  splinting,  or  by 
osteotomy  if  necessary.  When  the  patient  begins  to  walk  the 
foot  must  be  supported.  A  light  steel  upright  on  the  outer  side 
of  the  leg,  provided  T\"ith  a  T-strap  to  hold  the  leg  against  it, 
will  supply  the  place  of  the  missing  fibula.  As  the  gTowth  of 
the  tibia,  and  in  less  degTce  that  of  the  femur,  is  retarded  a  final 
shortening  of  three  or  more  inches  may  be  expected. 

Talipes  Varus  or  Equinovarus  Associated  with  Congenital 
Absence  of  the  Tibia. — Defective  formation  of  the  tibia  is  much 
less  common  than  that  of  the  fibula.  Myers^  has  collected  46 
cases.  Of  the  38  cases  in  which  the  sex  was  recorded,  25  were 
in  males  and  13  in  females.  In  31  instances  the  defect  was  of 
one  side;  in  IT  lx)th  tibise  were  defective.  In  most  of  the  cases 
the  femur  was  somewhat  shortened  and  its  lower  extremity  was 
imperfectly  developed.  In  a  third  of  the  cases  the  patella  was 
absent,  and  in  many  instances  other  malformations  were  present. 
In  nearly  all  the  cases  there  was  flexion  contraction  at  the  knee 
and  the  fibula  was  dislocated  backward.  The  foot  is  practically 
always  in  an  attitude  of  varus.  The  toes  may  be  normal,  but 
in  a  number  of  instances  the  great  toe  is  lacking.  In  possibly  a 
third  of  the  cases  a  portion  of  the  tibia,  usually  the  upper  ex- 
tremity, is  present.- 

The  jDrogiiosis  as  regards  a  useful  limb  is  extremely  bad. 
The  growth  of  both  the  thigh  and  the  leg  is  much  retarded,  and 
it  is  almost  impossible  to  balance  the  foot  upon  the  fibula  by  any 
form  of  brace. 

The  ordinary  treatment,  after  the  correction  of  the  deformity 
of  the  foot,  has  been  to  resect  the  extremities  of  the  femur  and 
the  fibula  to  induce  anchylosis.  Xo  final  results  have  been 
reported,  but  it  may  be  assumed  that  an  artificial  limb  would 
provide  a  more  useful  support  than  the  short  and  distorted  ex- 
tremity. 

Congenital  Deficiency  and  Hypertrophy. — The  leg  bones  may 
be  perfectly  formed,  but  one  or  more  bones  of  the  foot  itself  may 
be  absent.  In  these  cases,  after  the  reduction  of  the  deformity, 
a  support  to  hold  the  defective  foot  in  its  proper  relation  to  the 
leg  must  be  used. 

'Medical  Eeeord.  Julv  15,  1905. 

^  Lanois  and  Kuss  report  40  eases.     Eevue  d  'Orthopedie,  November,  1901. 


DEFOBMITIES  OF  TEE  FOOT. 


845 


The  foot  may  be  divided  into  two  parts,  so  that  it  resembles  a 
lobster  claw.  Supernimierary  toes,  or  deficiency  of  toes,  or 
hypertrophy  of  one  or  more  of  the  toes,  with  or  without  corre- 


riG.  573. 


Fig.  574. 


Congenital  deficiency  of  the  femur. 


Congenital  cedema  of  the  feet. 


sponding  overgrow^th  of  the  foot  or  leg,  are  not  extremely  un- 
common. 

These  deformities  must  be  treated  on  ordinary  surgical  prin- 
ciples.-^ 

Constricting  Bands. — Tightly  constricting  bands  of  scar-like 
tissue,  accompanied  by  deep  indentations  in  the  flesh  of  the 
foot  or  leg,  are  sometimes  seen.  These  are  supposed  to  be  caused 
by  amniotic  adhesions.  "  Spontaneous  amputations  "  of  toes  or 
of  the  foot  itself  are  due  to  the  same  cause  (Fig.  525). 

'  Ueber  Missbildungen  der  menschlichen  Gliedmassen  und  ihre  Entsteh- 
ungsweise,  Klausner,  1900. 


846       -  OBTHOPEDIC  SUEGEBY. 

In  ordinary  cases  the  bands  require  no  treatment,  but  if  tbey 
interfere  with  the  nutrition  of  the  foot  they  may  be  removed. 

Congenital  CEdema  of  the  Feet. — In  rare  instances,  some- 
times in  combination  with  deformity,  the  tissues  of  the  feet 
appear  to  be  (Edematous,  although  the  circulation  seems  to  be 
perfect.  The  condition  is  apparently  due  to  obstruction  of  the 
lymphatic  circulation  (Fig.  574). 

It  should  be  treated  by  massage  and  by  compression. 

Spina  Bifida  and  Talipes. — Talipes  with  spina  bifida  should 
be  treated  as  are  other  forms  of  club-foot.  If  paralysis  of  the 
lower  extremities  be  present,  as  is  often  the  case,  the  corrected 
feet  must  be  supported  as  in  the  ordinary  forms  of  paralytic 
deformitv. 


CHAPTEE   XXIII.      . 

DEFOEMITIES  OF  THE  FOOT   (Continued). 

ACQUIRED   TALIPES. 

In  the  account  of  the  congenital  deformities  of  the  foot  it 
was  stated  that  equinovarus  was  by  far  the  most  common,  and 
that  as  compared  with  it  the  other  deformities  were  of  slight 
importance. 

In  the  acquired  varieties  of  talipes  the  equinovarus  deformity 
is  much  less  common,  the  proportion  in  the  congenital  form 
being  Y7.4  per  cent,  and  in  the  acquired  30  per  cent,  of  the  total 
number.  Acquired  equinus  comes  next  in  frequency,  25.9  per 
cent,  as  compared  with  2.3  per  cent,  of  the  congenital  deform- 
ity; and  every  variety  and  combination  of  distortion  finds  its 
representative  in  acquired  talipes,  as  may  be  seen  in  the  tables. 
(See  page  794.) 

Etiology.— The  cause  of  acquired  talipes  is  usually  paralysis. 
In  the  table  of  statistics  it  will  be  seen  that  in  79.9  per  cent, 
the  paralysis  was  of  spinal  origin  (anterior  poliomyelitis).  In 
11.5  per  cent,  it  was  cerebral,  the  talipes  being  a  part  of  the 
deformity  of  hemiplegia  or  paraplegia.  In  a  few  cases  the 
deformity  was  caused  by  local  disease  or  by  local  paralysis,  and 
the  remainder,  or  7  per  cent.,  were  of  traumatic  origin. 

The  distinction  between  the  two  varieties  of  talipes,  congeni- 
tal and  acquired,  has  already  been  emphasized.  In  the  congeni- 
tal form  the  deformity  is  the  essential  disability,  for  when  de- 
formity has  been  rectified  the  most  difficult  part  of  the  treat- 
ment has  been  accomplished  and  perfect  cure  may  be  expected. 
In  the  acquired  form  the  straightening  of  the  foot  is  but  a  pre- 
liminary part  of  the  treatment,  for  cure  is  out  of  the  question 
except  in  that  small  proportion  of  cases  in  which  the  primary 
disease  of  the  spinal  cord  has  caused  no  permanent  injury  to  its 
structure,  or  in  which  the  deformity  was  the  result  of  some 
slight  or  passing  disability  or  of  disease  or  injury.  Congenital 
talipes  cannot  be  anticipated  or  prevented.  Acquired  talipes  is 
evidence  that  protective  treatment  has  been  neglected.  It  is  a 
result,  therefore,  that  may  be  foreseen,  and  thus  prevented. 

847 


848  OUTROPEDIC   SrSGEF^Y. 

Development  of  Deformity. — Tlie  characteristics  of  anterior 
poliomyelitis  are  described  elsewhere.  (Chapter  XVII.)  In 
its  effect  npon  the  foot  the  tisnal  sequence  is  somewhat  as  fol- 
lows :  At  the  onset  the  paralysis  is  often  widespread,  affecting 
an  entire  limb,  for  example :  then  follows  a  period  of  partial 
recovery,  after  which  the  amount  of  damage  that  the  spinal  cord 
has  sustained  may  be  estimated.  It  is  during  the  period  of 
partial  recovery,  the  six  months  or  more  following  the  attack, 
that  deformity  develops.  If.  for  example,  the  anterior  gTOup 
of  leg  muscles  is  paralyzed,  the  foot  habitually  hangs  downward, 
an  attitude  induced  by  the  force  of  gravity  and  by  the  contrac- 
tion of  the  unaffected  posterior  gTOtip.  If  the  attitude  persists 
the  tissues  accommodate  themselves  to  the  new  position;  the 
active  muscles  which  are  never  extended  to  their  normal  limit 
become  structurally  shortened,  while  the  weakened  or  paralyzed 
muscles  are  correspondingly  lengthened.  Even  within  a  week 
or  two  after  the  onset  of  the  paralysis  the  evidences  of  progres- 
sive deformity  are  plain.  The  contracted  tissues  resist  passive 
motion  in  the  directions  opposed  to  the  habitual  attitude,  and 
the  child  shows  evidence  of  pain  if  force  is  used  to  increase  the 
limited  range  of  motion.  As  has  been  stated  already,  acquired 
talipes  is  an  unnecessary  deformity.  It  may  be  prevented  by 
supporting  the  paralyzed  part  in  a  right-angled  relation  to  the 
limb,  and  by  systematic  passive  movements  throughout  the  entire 
range  of  normal  motions. 

Anterior  poliomyelitis  is  most  common  during  the  second 
year  of  life,  or  when  the  child  has  already  begun  to  walk.  When 
the  first  or  more  general  effect  of  the  disease  has  passed  away 
the  child  again  uses  the  disabled  lim])  as  best  it  may ;  thtis  the 
distortion  of  the  foot  is  increased  and  confirmed  by  the  weight 
of  the  body  and  by  functional  use  in  the  abnormal  attitude. 

The  final  deformity,  in  a  particular  case,  can  be  predicted 
from  knowledge  of  the  ftmction  of  the  muscles  which  have  been 
disabled.  Tor  example,  paralysis  of  the  tibialis  antictis,  the 
most  powerful  dorsiflexor  and  invertor  of  the  anterior  group, 
must  result  in  equinovalgais.  If  the  peroneal  group  is  affected 
varus  will  follow.  Paralysis  of  the  calf  muscles  will  cause 
calcaneus.  Paresis  or  paralysis  of  the  entire  anterior  group 
will  cause  equinus.  If  all  the  muscles  are  paralyzed,  what  is 
called  a  dangle-foot  is  the  result ;  the  atrophied  member  dangles 
with  but  little  tendency  to  deformity  unless  it  is  capable  of  use, 
when  it  is  usuallv  forced  into  an  attitude  of  varus  or  val<i-us. 


DEFOBMITIES  OF  THE  FOOT.  849 

A  slight  degree  of  j)aralysis  may  cause  no  immediate  dis- 
ability and  yet  it  may  be  sufficient  to  induce  deformity  in  later 
years.  This  fact  has  been  mentioned  in  the  etiology  of  the  con- 
tracted foot. 

Differential  Diagnosis  between  Congenital  and  Acquired  De- 
formity.— The  history  itself  usually  indicates  the  etiology,  for 
deformity  of  the  foot  at  birth  is  never  overlooked  by  the  mother. 
Acquired  talipes  is  of  slow  development,  and  it  is  practically 
always  preceded  by  disease,  weakness,  or  injury. 

In  paralytic  talipes  (anterior  poliomyelitis)  there  is  evidence 
of  paralysis  in  loss  of  function  of  certain  muscles,  as  shown  by 
electrical  stimulation  or  by  pricking  the  foot  with  a  pin;  later, 
in  the  atrophy  of  the  muscles  and  often  in  the  evident  change 
in  the  nutrition  and  diminished  growth  of  the  limb. 

Only  in  neglected  and  extreme  cases  of  talijDes  in  the  adoles- 
cent or  adult  could  there  be  difficulty  in  distinguishing  be- 
tween the  acquired  and  the  congenital  deformity.  In  rare  in- 
stances, it  is  true,  paralysis  may  be  present  at  birth,  due  to  in- 
trauterine disease  or  to  defect  in  the  nervous  apparatus.  In 
such  cases  the  cause  of  the  paralysis  is  usually  apparent  (spina 
bifida  or  spastic  paralysis  associated  with  defective  cerebral 
development),  and  the  treatment  does  not  differ  from  that  of 
the  acquired  form. 

ACQUIRED  TALIPES  EQUINUS. 

In  well-marked  equinus  the  foot  is  plantar  flexed  to  its  full 
limit,  and  it  is  fixed  in  this  attitude  by  the  shortened  structures 
of  which  the  tendo  Achillis  is  the  most  important.  The  patient 
walks  upon  the  heads  of  the  metatarsal  bones,  the  toes  being 
dorsiflexed  to  accommodate  the  deformity.  The  arch  of  the  foot 
is  increased  in  depth  and  the  tissues  of  the  sole,  particularly  the 
plantar  fascia,  are  contracted.  The  foot  is  broadened  and  short- 
ened, the  breadth  being  especially  increased  at  the  anterior  meta- 
tarsal region  (Fig.  520),  Corresponding  to  the  exaggerated 
depth  of  the  arch,  the  dorsum  projects,  the  cuneiform  bones  are 
prominent,  and  the  head  and  body  of  the  displaced  astragalus 
may  be  felt  beneath  the  skin  on  the  anterior  surface  of  the  foot. 
In  the  slighter  degrees  of  the  deformity,  when  the  patient  still 
walks  upon  the  sole  of  the  foot,  the  toes  are  usually  dorsiflexed 
— an  attitude  due  apparently  to  the  overaction  of  the  extensor 
longus  digitorum  and  proprius  hallucis,  as  aids  in  dorsiflexion 
54 


850 


OBTHOPEDIC  SUBGEBY. 


(Fig.  575).  In  rare  instances,  and  only  in  those  cases  inwMch 
all  the  anterior  muscles  are  paralyzed,  the  toes  may  be  plantar 
flexed  the  patient  walking  upon  their  dorsal  surfaces. 

The  cavus  or  increased  depth  of  the  arch  is  due  primarily  to 
the  flexion  of  the  forefoot  at  the  mediotarsal  joint,  and  in  many 
instances  this  dropping  of  the  forefoot  is  in  great  degree  respon- 
sible for  the  equinus;  in  fact,  the  os  calcis  is  rarely  plantar 
flexed  to  the  degree  commonly  found  in  the  ordinary  congenital 

equinus. 

Fig.  575. 


Acquired  talipes  equinus,  stiowing  tlie  limit  of  dorsal  flexion. 


The  cases  of  slight  equinus  combined  with  cavus  have  been 
described  already  under  the  title  of  the  Contracted  Foot  (page 
748). 

Etiology. — Equinus  is  the  most  common  of  the  forms  of  tali- 
pes acquired  in  later  life.  Anterior  poliomyelitis,  although  by 
far  the  most  common  cause,  is  by  no  means  as  important  in  the 
etiology  of  this  as  of  other  varieties  of  deformity.  The  nerve 
supply  of  the  anterior  muscles  of  the  foot  seems  to  be  particu- 
larly susceptible,  and  toe-drop,  from  neuritis  of  various  types,  is 
not  uncommon. 

Equinus  may  be  a  result  of  disease  of  cerebral  origin,  or  even, 
in  rare  instances,  of  pseudohypertrophic  muscular  paralysis, 
locomotor  ataxia,  and  the  like.  It  is  sometimes  induced  by 
habitual  posture,  as  by  long  confinement  in  bed  for  the  treat- 
ment of  fracture  or  during  the  treatment  of  hip  disease  by  ap- 


DEFOBMITIES  OF  TEE  FOOT. 


851 


Fig.  576. 


j>aratiis.  Or  the  contraction  may  be  an  effect  of  voluntary 
posture,  as  when  the  patient  habitually  walks  upon  the  toes 
because  of  a  short  limb.  It  is  a  very  common  sequel  of  neglected 
disease  at  the  ankle-joint,  and  it  may  be  a  result  of  direct  injury. 

The  changes  in  the  internal  structure  of  the  foot  are  similar 
to  those  that  follow  other  forms  of  deformity ;  the  tissues  on  the 
long  side  are  lengthened  and  at- 
tenuated, while  those  on  the 
short  side  become  contracted. 
The  bones  themselves  are  but 
little  changed  in  gross  appear- 
ance, but  the  articulating  sur- 
faces are  in  abnormal  relation 
to  one  another ;  for  example, 
only  the  posterior  part  of  the 
astragalus  may  be  contained 
within  the  malleoli  in  relation 
to  the  tibia,  while  only  the  lower 
part  of  its  anterior  surface  ar- 
ticulates with  the  navicular.  In 
all  cases  of  equinus  there  is  a 
strong  tendency  toAvard  varus 
or  valgus.  This  is  especially 
noticeable  in  those  of  paralytic 
origin. 

Symptoms. ^The  effects  of 
the  deformity  vary.  If  the  limb 
is  actually  shorter  than  its  fel- 
low, so  that  the  lengthening 
caused  by  the  extension  of  the 
foot  is  no  more  than  a  sufficient  compensation,  and  if  the  foot  is 
firmly  fixed  in  the  deformed  position,  there  is  but  little  dis- 
ability and  the  principal  discomfort  is  from  corns  or  calluses 
beneath  the  metatarsal  bones. 

If  the  limb  is  not  shorter,  the  additional  length  caused  by  the 
equinus  must  be  compensated  by  a  tilting  of  the  pelvis  and 
lateral  deviation  of  the  spine.  This  often  causes  discomfort  in 
the  lumbar  region.  The  gait  in  this  class  of  cases  is  always 
awkward,  giving  the  impression  as  of  stepping  over  an  obstacle. 

If  the  foot  is  not  fixed  in  the  attitude  of  equinus^ — that  is,  if 
it  hangs  downward  when  it  is  lifted — the  gait  is  very  awkward, 
because  of  the  insecurity  and  because  of  the  exaggerated  flexion 
at  the  knee  necessary  to  lift  the  pendent  foot. 


Tuberculous  "  Rheumatism 
equinus   deformity. 


and 


852  OBTHOPEDIC  SUBGEBY. 

If  the  equinus  is  extreme  the  limb  is  usually  flexed  at  the 
knee  when  in  use.  If  the  equinus  is  so  slight  that  the  foot  may 
be  used  in  the  plantigrade  position,  the  strain  resulting  from  the 
limitation  of  dorsal  flexion  is  felt  at  the  knee ;  and  in  childhood 
especially  there  is  often  a  well-marked  tendency  to  overextension 
or  recurvation,  caused  by  the  effort  to  place  the  heel  upon  the 
ground. 

In  the  slight  degrees  of  equinus,  discomfort  about  the  calf  is 
experienced;  the  limitation  of  dorsal  flexion  causes  a  shortened 
stride  and  awkward  gait,  while  an  unguarded  step  that  throws 
a  sudden  strain  upon  the  rigid  heel  cord  is  felt  as  a  shock  and 
strain  through  the  leg  and  body.  Very  often  the  patient  com- 
plains of  pain  about  the  metatarsal  bones  (anterior  metatar- 
salgia),  and  if  the  equinus  is  accompanied  by  a  slight  degree  of 
valg-us,  as  is  not  uncommon,  symptoms  of  the  weak  foot  may  be 
present. 

The  progTLOsis  as  to  permanent  cure  depends,  of  course,  upon 
the  cause  of  the  deformity.  When  it  is  simply  the  result  of  pos- 
ture or  of  the  ordinary  form  of  neuritis  and  the  like,  permanent 
cure  may  be  expected.  In  many  of  the  cases  caused  by  anterior 
poliomyelitis  there  has  been  recovery,  complete  or  partial,  of  the 
original  injury  to  the  spinal  centres.  But  although  the  power 
has  been  regained,  it  cannot  be  exercised  because  the  foot  is  held 
in  the  distorted  position  by  the  contracted  tissues.  In  such  in- 
stances practical  cure  may  be  predicted  if,  after  the  overcorrec- 
tion of  deformity,  sufficient  time  is  allowed  for  the  overstretched 
and  atrophied  muscles  to  regain  their  proper  length  and  volume. 

Treatment. — In  the  cases  of  fixed  equinus  with  a  shortened 
limb  in  which  the  patient  suffers  no  discomfort  a  shoe  should  be 
so  built  that  the  entire  sole  may  support  the  weight.  In  the 
more  extreme  cases  in  which  the  limb  is  short  and  the  foot  is 
atrophied  an  extension  shoe,  attached  after  the  manner  of  an 
artificial  leg,  may  be  worn  with  comfort  and  with  but  little 
evidence  of  deformity. 

In  the  ordinary  cases,  whether  permanent  cure  is  expected  or 
not,  the  rule  holds  good  that  the  heel  should  bear  wei2:ht,  and 
that  the  range  of  dorsal  flexion  should  not  be  limited  when  the 
calf  muscle  retains  its  power.  If  the  paralysis  is  permanent  the 
foot  must  be  supported  after  the  deformity  has  been  corrected ; 
but  even  in  this  class  the  gait  may  be  improved  and  the  discom- 
fort may  be  relieved  by  removing  the  restrictions  to  normal 
motion. 


DEFORMITIES  OF  THE  FOOT.  853 

The  slight  degrees  of  equiniis  in  young  subjects  may  be  over- 
come by  simple  manipulation  or  by  retention  in  a  splint  or  in  a 
plaster  bandage.  If  the  foot  is  fixed  by  a  j^laster  bandage  at  a 
right  angle  to  the  leg  it  will  be  found  after  a  few  weeks  that  the 
range  of  dorsal  flexion  has  been  increased  by  the  rest  and  by 
functional  use.  Manual  stretching  of  the  contracted  tissues  is 
also  of  service;  for  example,  the  patient  being  seated  extends  the 
limb ;  the  surgeon  stands  in  front  of  him,  one  hand  holds  the 
leg  firmly  at  the  ankle,  and  the  other  grasps  the  foot,  which  is 
then  dorsiflexed  over  and  over  again  with  as  much  force  as  is 
consistent  with  the  comfort  of  the  patient. 

Certain  forms  of  apparatus,  for  example,  the  Shaffer  exten- 
sion shoe,  may  be  employed  with  advantage  in  cases  of  slight 
deformity. 

Immediate  Correction  of  Deformity. — Attention  has  been  called 
to  the  cavus  as  an  important  element  in  equinus,  and  whenever 
one  attempts  to  correct  the  equinus  deformity  the  exaggerated 
arch. should  first  be  reduced  to  its  normal  depth,  otherwise  the 
foot  will  appear  stunted  and  deformed. 

One  of  the  most  effective  procedures  is  forcible  reduction  by 
means  of  the  Thomas  wrench  (Fig.  556).  The  resistant  bands 
of  the  plantar  fascia  are  first  divided  subcutaneously,  the  wrench 
is  then  fixed  to  the  foot,  and  by  sudden  force  exerted  against 
the  resistant  tendo  Achillis  the  foot  is  straightened,  the  con- 
tracted tissues  being  ruptured  or  stretched  to  the  proper  degree. 
The  resistance  to  normal  dorsal  flexion  is  then  overcome  by 
manual  force,  or,  if  this  is  ineffective,  by  subcutaneous  division 
of  the  tendo  Achillis,  and  the  foot  is  fixed  by  a  plaster-of-Paris 
bandage  in  an  attitude  of  dorsiflexion.  If  as  is  usual  the  toes 
are  contracted,  the  deformity  should  be  reduced  in  the  manner 
described.     (See  Contracted  Foot.) 

As  the  patient  is  encouraged  to  walk  upon  the  foot  as  soon  as 
possible,  the  weight  of  the  body  forcing  the  relaxed  tissues 
against  the  plaster  sole,  reinforced,  if  necessary,  by  a  wooden 
foot-plate  completes  the  flattening  of  the  arch.  In  many  of  these 
cases  the  knee  has  been  overextended  by  use  in  the  deformed 
attitude,  so  that  the  habitual  flexion  necessary  to  bring  the  dorsi- 
flexed foot  upon  the  ground  during  the  two  months  allowed  for 
the  complete  union  of  the  divided  tendon  is  of  benefit,  as  it 
serves  to  correct  this  secondary  weakness  and  deformity. 

The  Tonic  Effect  of  Immediate  Corkection. — The  im- 
portance of  the  tonic  effect  of  immediate  relief  of  the  strain  of 


854 


ORTHOPEDIC  SUBGEEY. 


the  deformed  position  upon  the  weak  anterior  group  of  muscles, 
together  with  the  complete  relaxation  of  the  overstretched  tis- 
sues, during  the  long  rest  in  the  overcorrected  position  is  not 
generally  appreciated.  Whenever  the  weakened  muscles  after 
paralysis  show  by  tests,  electrical  or  otherwise,  that  they  have 
recovered  their  power  in  part,  overcorrection  of  the  deformity 


Fig.  577. 


Fig.  578. 


A   brace    with    a    "  limited "    joint, 
allowing  slight  motion   at  the   ankle. 


A  brace  to  prevent  foot-drop.    One 
upright   is   often   sufficient. 


should  be  the  treatment  of  selection.  The  application  of  elec- 
tricity or  other  form  of  stimulation  to  muscles  that  are  unable  to 
exercise  their  function  because  of  contraction  of  the  opposing  tis- 
sues is  practically  useless ;  nor  is  any  other  form  of  artificial  stimu- 
lation equal  to  that  of  the  functional  use,  which  is  made  pos- 
sible by  the  removal  of  the  deformity  and  by  the  employment  of 
proper  support.  Equinus,  more  often  than  any  other  deformity, 
is  the  result  of  slight  or  temporary  disability  of  the  anterior 
group  of  muscles,  and  not  infrequently  perfect  cure  seems  to 
have  been  attained  when  the  plaster  bandage  is  finally  removed, 
usually  at  the  end  of  two  months  or  more;  but  even  in  such 
cases  the  application  of  a  simple  support  to  hold  the  foot  at  a 


DEFOBMITIES  OF  TEE  FOOT. 


855 


right  angle  with  the  leg  for  several  months  is  advisable  while  a 
higher  brace  to  hold  the  foot  during  the  night  in  the  original 
attitude  of  overcorrection  is  an  effective  means  of  preventing 
relapse.  The  after-treatment  by  massage,  muscle-beating,  elec- 
tricity, and  the  like,  combined  with  methodical  passive  move- 
ments to  the  limit  of  dorsal  flexion  to  guard  against  recontrac- 
tion  of  the  calf  muscle,  should  be  continued  for  a  long  time  or 
until  the  muscular  balance  has  been  regained. 


Fig.  579. 


fTs 


An  effective  and  inconspicuous  support  for  paralytic  toe-drop.  An  upright 
of  light  tempered  steel,  carefully  adjusted  to  the  inner  side  of  the  leg  and  ankle, 
provided  with  a  light  calf  band.  This  is  strengthened  by  a  posterior  support 
attached  to  the  upright.  The  lovs^er  end  of  the  brace  is  arranged  as  a  caliper 
and  is  fitted  to  the  metal  disk,  of  which  two  views  are  shown.  A  depression  is 
cut  in  the  heel  of  the  shoe  for  the  disk,  as  is  shown  in  the  diagram.  Two  strong 
elastic  tapes  are  sewed  to  the  leather  of  the  shoe.  These  are  attached  to  the 
studs  on  the  front  of  the  calf  band,  and  thus  the  toe-drop  is  prevented.  (See 
Fig.  580.) 

Support  is,  of  course,  necessary,  iji  cases  of  hopeless  paralysis, 
to  hold  the  foot  at  a  right  angle  with  the  leg.  The  common 
form  is  a  simple  steel  sole-plate  of  sufficient  size  to  support  the 
sole,  and  the  toes,  also,  if  their  muscles  are  paralyzed,  attached 
to  a  light  upright,  provided  with  a  calf  band.  The  upright  is 
usually  applied  on  the  inner  side  of  the  leg,  where  it  is  least 


856 


OETEOPEDIC   SUEGERY. 


noticeable.  At  the  aukle  there  is  a  ''stop-joint,"  which  allows 
dorsiflexion  but  prevents  the  toe-drop.  This,  when  properly 
fitted,  can  be  placed  inside  the  ordinary  shoe,  as  the  paralyzed 
foot  is  nsnally  somewhat  smaller  than  its  fellow  (Fig.  578).  If 
the  toes  do  not  need  support,  the  upright  can  be  attached  to  the 

outside  of  the  shoe  and  the 
^^<^-  ^^^-  foot-plate     may     be     dis- 

pensed with;  or,  the  up- 
right may  be  concealed  by 
introducing  it  inside  the 
shoe  to  a  joint  sunk  in  the 
heel,  the  toe-drop  being 
prevented  by  straps  pass- 
ing from  the  front  of  the 
upper  leather  of  the  shoe 
to  the  calf  band  (Fig. 
579). 

Arthrodesis.  — I  n  this 
class  of  cases  in  which  the 
anterior  muscles  are  com- 
pletely paralyzed  the  oper- 
ation of  arthrodesis  for  the 
purpose  of  fixing  the  foot 
at  a  right  angle  with  the 
leg  is  of  value  in  later 
childhood.  In  most  in- 
stances the  mediotarsal  as 
well  as  the  ankle-joint 
must  be  operated  on.  Un- 
der the  Esmarch  bandage 
the  two  joints  are  opened 
by  an  incision  in  the  cen- 
tre of  the  foot,  beginning 
about  one  inch  above  the  ankle-joint  and  extending  downward 
for  about  three  inches.  The  cartilaginous  surfaces  of  the  astrag- 
alus and  leg  bones  may  be  removed  with  a  narrow-bladed  knife 
or  thin,  sharp  chisel,  while  the  foot  is  held  in  plantar  flexion. 
At  the  mediotarsal  joint  a  thin,  wedge-shaped  section,  base  up- 
ward, including  the  astragalonavicular  and  calcaneocuboid 
joints,  may  be  removed  also  in  order  to  prevent  the  subsequent 
sinking  of  the  forefoot.  The  ankle  joint  can  be  more  com- 
pletely exposed  by  the  external  lateral  incision  as  described 
under  astragalectomy. 


The  same  appliance  (Fig.  527)  provided 
with  a  foot  plate  of  metal  or  of  wood  as 
shown  in  the  diagram.  This  modification 
is  useful  if  the  paralysis  is  complete  or  if 
the   foot   is    much    atrophied. 


DEFOEMITIES  OF  TEE  FOOT. 


857 


If  there  is  restriction  of  dorsal  flexion  the  foot  should  he 
forced  up  to  a  right  angle  with  the  leg  against  the  resistance  of 
the  tendo  Achillis,  thus  pressing  the  denuded  surfaces  together. 
In  other  instances  silk  sutures  may  he  passed  through  the  peri- 
osteum of  the  opposing  bones.  The  wound  is  then  closed  with 
catg-ut  ligatures  and  a  plaster-of-Paris  bandage  is  applied  to 
hold  the  foot  at  a  right  angle  with  the  leg.  Operations  of  this 
character  on  the  bones  are  sometimes  followed  by  swelling.  On 
this  account  the  bandage  should  be  applied  over  a  thick  layer  of 

Fig.  581. 


Support  and  elevation  after  arthrodesis. 

elastic  cotton  and  the  foot  should  be  elevated.  As  soon  as  the 
discomfort  has  subsided  the  patient  should  use  the  foot  in 
walking.  jSTo  support  is  equal  in  efficiency  to  the  plaster  band- 
age. This  should  be  worn  for  several  months,  when  it  may  be 
replaced  by  a  light  supporting  brace  of  the  Judson  type  (Fig. 
563 J.  Equinus  due  to  posture  or  to  disease,  not  involving  par- 
alysis, may  be  cured  by  simple  correction  of  the  deformity.  Re- 
sistant deformity  following  fractures  at  the  ankle  may  be  over- 
come satisfactorily  by  astragalectomy. 


ACQUIRED  TALIPES  CALCANEUS. 

Acquired  talipes  calcaneus  is  much  less  common  than  equinus, 
and  it  is  practically  always  of  paralytic  origin  (anterior  polio- 
myelitis), although  cases  of  calcaneus  following  injury  or 
disease  or  distortion  of  the  limb  are  occasionally  seen. 


8o8  OBTHOPEDIC  SUEGEEY. 

Etiology. — There  are  several  varieties  or  grades  of  tlie  de- 
formity. If  all  the  muscles  of  the  posterior  group  have  been 
paralyzed,  the  foot  soon  assumes  an  attitude  of  slight  dorsi-. 
flexion,  and  the  range  of  plantar  flexion  is  gradually  lessened  by 
secondary  contractions.  This  variety  resembles  closely  the  con- 
genital form,  (simple  calcaneus)  (Fig.  521).  In  the  ordinary 
and  typical  form  of  calcaneus,  when  fully  develoj)ed,  the  patient 
walks,  as  the  name  implies,  on  an  elongated  heel.  The  arch  of 
the  foot  is  much  increased  in  depth,  and  the  forefoot  is  atrophied 
and  useless  (calcaneocavus)   (Fig.  584). 

Development  of  Deformity. — The  development  of  the  deformity 
is  somewhat  as  follows :  The  tension  and  support  of  the  calf 
muscle  having  been  lost  the  os  calcis  eventually  assumes  an  atti- 
tude of  extreme  dorsiflexion.  It  stands  on  end,  so  that  its  pos- 
terior surface  becomes  inferior.  The  projection  of  the  heel  is 
first  lessened  and  finally  lost.  The  change  in  the  position  of  the 
OS  calcis  increases  the  distance  from  the  malleoli  to  the  ground, 
deepens  the  longitudinal  arch,  and  shortens  the  foot ;  thus  cavus 
is  a  later  complication  of  all  cases  of  paralytic  calcaneus.  If 
the  entire  posterior  gToup  of  muscles  is  paralyzed,  while  the 
anterior  muscles  are  unaffected,  the  foot  will  be  somewhat  dorsi- 
flexed  and  the  cavus  will  be  less  marked.  If  the  calf  muscle  only 
(ga&trocnemius  and  soleus)  is  paralyzed,  the  remaining  muscles 
of  the  posterior  gToup  will  counterbalance  the  dorsiflexors  and  at 
the  same  time  increase  the  cavus.  In  all  cases  the  range  of 
plantar  flexion  is  lessened.  In  many  instances  one  or  more  of 
the  lateral  muscles  may  be  paralyzed,  in  which  case  the  foot  is 
usually  turned  toward  valgus.  The  changes  primarily  caused 
by  the  paralysis  and  by  unopposed  muscular  action  become  fixed 
by  habitual  use  and  by  secondary  adaptation  of  the  tissues.  The 
heel  only  is  used  in  walking,  and  the  area  of  callus  indicating 
its  weight-bearing  surface  becomes  much  enlarged,  and  to  it 
forefoot  and  toes  become  a  mere  appendage,  a  striking  illustra- 
tion of  the  atrophy  that  follows  disuse  (Fig.  584). 

Symptoms. — The  gait  is  shambling,  the  patient,  who  is,  as  it 
were,  "hamstrung,"  stamj)s  along  upon  the  insecure  heel  in  a 
manner  which  is  easily  recognizable  by  one  familiar  with  the 
deformity.  The  changes  in  the  internal  structure  of  the  foot, 
the  inevitable  adaptations  to  the  deformity,  do  not  call  for 
special  description. 

Treatment. — When  the  diagnosis  of  paralysis  of  the  calf 
muscle  is  made  one  may  predict,  unless  recovery  takes  place,  a 


DEFORMITIES  OF  THE  FOOT.  859 

deformity  such  as  has  been  described.  This  deformity  may  be 
lessened  or  even  prevented  by  proper  support,  by  massage  and 
methodical  stretching  of  the  tissues  that  have  a  tendency  to  con- 
tract. The  form  of  brace  used  for  walking  and  support  should 
be  provided  with  a  sole  plate,  upright,  and  calf  band,  as  already 

Fig.  582.  Fig.  583. 


Judson's   brace   for   calcaneus   deformity. 

described  in  the  treatment  of  paralytic  equinus.  If  motion  is 
permitted  at  the  ankle  it  should  be  in  plantar  flexion  only,  the 
stop  being  the  reverse  of  that  used  in  equinus ;  or,  as  this  form 
of  check  entails  much  strain  upon  the  joint,  it  may  be  omitted 
(Figs.  582-583).  A  still  stronger  brace  is  that  shown  in 
Fig.  589.  Thus  the  strain,  removed  from  the  weakened  tissues, 
is  borne  by  the  anterior  surface  of  the  leg.  Other  forms  of 
braces  are  sometimes  employed,  provided  with  elastic  bands 
to  supply  the  place  of  the  calf  muscle;  but,  as  a  rule,  the  im- 
provement in  gait  hardly  compensates  for  the  difficulty  in  ad- 
justment or  the  conspicuousness  of  the  appliance. 

The  most  important  part  of  the  actual  deformity  of  calcaneus 
is  the  cavus,  and  in  confirmed  cases  it  is  practically  impossible 
to  reduce  this  directly,  because  the  loss  of  resistance  of  the  tendo 
Achillis  takes  away  the  point  of  fixation  against  which  effective 
force  can  be  exerted.  If  the  deformity  is  not  marked  the  foot 
may  be  drawn  as  far  as  possible  toward  equinus  and  fixed  in  a 
plaster  bandage,  the  sole  part  being  strengihened  by  the  inser- 


860 


ORTHOPEDIC  SUBGEBY. 


tion  of  a  tMii  board.  Upon  this  tlie  patient  may  walk,  the 
heel  being  bnilt  up  with  cork  wedges  to  make  the  sole  level. 
When  the  contraction  of  the  anterior  tissues  has  been  overcome 
the  brace  is  applied  and  the  usual  treatment  of  manipulation 
and  massage  is  continued  (Fig.  591  j. 

The  method  of  prolonged  fixation  in  the  attitude  of  equinus 
by  means  of  the  plaster  bandage  is  often  of  value  in  early  child- 
hood, if  the  paralysis  is  not  complete,  and  cures  of  apparently 
hopeless  cases  by  this  means  have  been  reported.-^ 

Fig.  584. 


Paralytic    calcaneus,    showing   secondary    changes    in    contour. 


Operative  Treatment. — In  more  extreme  cases  immediate  re- 
duction of  the  deformity  under  anaesthesia  may  be  attempted. 
The  contracted  tissues,  more  particularly  the  plantar  fascia, 
may  be  divided  subcutaneously  or  by  open  incision ;  then  by 
forcible  manipulation  or  wrenching  the  sole  may  be  somewhat 
lengthened  and  the  heel  pushed  upward  and  backward  to  permit 
of  slight  plantar  flexion.     In  this  attitude  the  foot  should  be 

^  Gibney,  Transactions  of  the  American  Orthopedic  Association,  1900, 
vol.  xiii. 


DEFORMITIES  OF  THE  FOOT. 


861 


fixed  bj  means  of  a  plaster  bandage.  In  the  reduction  of  the 
deformity  one  must  not  merely  force  the  forefoot  downward,  as 
this  would  simply  increase  the  cavus,  but  whatever  correction  is 
accomplished  should  be  by  means  of  elevation  of  the  os  calcis 
and  elongation  of  the  tissues  of  the  sole  of  the  foot.  In  cases  of 
extreme  deformity  the  contracted  tissues  in  the  anterior  aspect 
of  the  ankle  must  be  divided  also. 

Fig.  585. 


Talipes   calcaneus   due  to   paralysis   of  the   calf   muscle    (gastrocnemius   and 
soleus,  illustrating  the  typical  deformity  of  moderate  degree.     See  Fig.  .587. 


In  some  instances  the  improved  position  of  the  os  calcis  may 
be  assured  by  shortening  the  tendo  Achillis,  as  first  performed 
by  Willett,  of  London.^ 

Willett's  Operation  for  Calcaneus. — A  Y-shaped  incision  about 
two  inches  in  length  is  made  through  the  tissues  down  to  the 
tendon.  At  the  lower  vertical  part  of  the  incision,  which  is 
continued  down  to  the  tuberosity  of  the  os  calcis,  the  tendon  is 
dissected  from  the  surrounding  parts.  It  is  then  divided  in 
an  oblique  direction  from  within  outward  and  downward,  and 
the   heel  having  been   pushed  upward  as  far  as  possible  the 

^St.  Bartholomew's  Hospital  Eeports,  1880,  vol.  xvi.,  p.  309. 


862 


ORTHOPEDIC  SUBGEBY. 


divided  ends  are  overlapped  and  sutured;  tlie  flap  of  skin  is 
drawn  downv^ard  at  the  same  time,  so  that  the  Y-incision  is 


Fig.  586. 


Talipes  calcaneus  in  early  childhood. 


converted  into  the  shape  of-  a  V.     According  to  Mr.  Willett's 
original  directions,  deep  sutures  are  passed  through  the  skin 


Fig.  587. 


Illustrating  the  effect  of  the  author's  operation  in  restoring  symmetry. 
Compare  with  Fig.   585. 

flaps  and  through  the  tendon  on  either  side,  so  that  all  the 
tissues  are  united.     The  foot  is  then  fixed  in  a  plaster  bandage 


DEFOBMITIES  OF  TEE  FOOT.  863 

in  an  attitude  of  equinns.  As  soon  as  practicable  the  patient 
begins  to  use  tbe  foot,  wearing  a  high  heel  to  compensate  for 
the  elevation  of  the  sole. 

Palliative  operations  of  this  class  aside  from  lessening  de- 
formity may  be  of  service  in  those  cases  in  v^hich  some  power 
remains  in  the  calf  muscle.  In  cases  of  complete  paralysis  the 
shortened  tendon  offers  some  resistance  to  deformity,  but  unless 
support  is  used  afterward  the  tissues  will  stretch  under  the 
strain  of  use ;  thus  the  treatment  should  always  be  supplemented 
by  a  brace  of  the  character  already  described. 

Astragalectomy,  Arthrodesis,  Tendon  Transplantation,  and  Back- 
ward Displacement  of  the  Foot  (the  Author's  Operation"). — More 
effective  treatment  is  indicated  in  cases  of  confirmed  calcaneus 
and  especially  calcaneus  combined  with  lateral  deformity  which 
makes  the  adjustment  of  a  brace  difficult. 


The  iilastcr  bandage  and  the  attitude  after  the  operation. 

A  long,  curved,  external  incision  is  made,  passing  from  a 
point  behind  and  above  the  external  malleolus  below  its  ex- 
tremity and  terminating  at  the  outer  aspect  of  the  head  of  the 
astragalus.  The  peronei  tendons  are  divided  just  in  front  of 
the  malleolus  and  they  are  then  completely  separated  from  their 
sheaths  and  drawn-  backward.  The  lateral  ligaments  are  then 
divided  and  the  joint  is  opened.  The  interosseous  ligament  is 
cut  through  and  the  foot  is  twisted  inward.  When  the  attach- 
ments to  the  navicular  have  been  freed  the  astragalus  may  be 
removed.  A  thin  section  of  bone  is  then  cut  from  the  outer 
surface  of  the  adjoining  os  calcis  and  cuboid  bones,  and  on  the 
inner  side  the  calcaneonavicular  ligament  is  partially  separated 
from  its  navicular  attachment.     The  lateral  ligaments  are  freed 

^  American  Journal  of  the  Medical  Sciences,  November,  1901,  and  Annals 
of  Surgery,  February,  1908.      Am.  J.  Orth.  Surgery,  August,  1910. 


864 


OBTHOPEDIC  SUBGEBY. 

Fig.  589. 


An  effective ,  brace  for  talipes  calcaneus,  consisting  of  two  light  lateral 
steel  bars  joined  above  by  a  padded  band  of  steel,  which  crosses  the  upper  third 
of  the  tibia,  and  below  by  a  narrow  sole  plate.  A  leather  heel  support  also 
adds  somewhat  to  the  efBciency  of  the  apparatus.  The  heel  should  be  corre- 
spondingly elevated  by  a  cork  wedge  placed  within  the  shoe. 


Fig.  590. 


The  foot  after  the  author's  operation  for  calcaneovalgus  showing  the  restoration 
of  symmetry.     Also  a  simple  brace  to  be  worn  within  the  shoe. 


DEFOBMITIES  OF  THE  FOOT. 


865 


from  the  two  malleoli  and  the  cartilage  is  removed  from  their 
inner  surfaces.  The  foot  is  then  displaced  backward  as  far  as 
possible  so  that  the  external  malleolus  may  cover  the  calcaneo- 
cuboid junction  while  the  inner  is  forced  into  the  depression 
behind  the  navicular,  the  malleolus  being  changed  in  shape  if 
necessary  to  assure  accurate  adjustment.  Finally,  the  peronei 
tendons  are  drawn  through  an  023ening  in  the  tendo  Achillis  and 
are  sewed  to  it  and  to  the  os  calcis  with  strong  silk  sutures.    The 

Fig.  591. 


The  plaster  bandage  with  cork  wedge  holding  the  foot  in  equinus. 

wound  is  closed  without  drainage,  and  the  foot  is  then  held  in 
an  attitude  of  equinovalgus  by  a  plaster  bandage  fixing  the  leg 
at  a  right  angle  to  the  thigh  as  showai  in  the  illustration.  The 
object  of  the  removal  of  the  astragalus  is  to  assure  stability  and 
to  prevent  lateral  deformity  by  placing  the  leg  bones  directly 
upon  the  foot.  Incidentally  it  restores  the  symmetry  of  the 
foot.  The  object  of  the  backward  displacement  of  the  foot  is 
to  direct  the  weight  upon  its  centre  and  thus  to  remove  the 
adverse  leverage  and  to  prevent  dorsak  flexion  by  direct  contact 
of  the  tarsal  bones  with  the  anterior  margin  of  the  tibia.  The 
tendon  transplantation  is  an  additional  safeguard  against  de- 
formity and  of  service  in  restoring  function  (Fig.  592). 

In  about  three  weeks  the  long  plaster  is  removed  and  a  short 
one  is  substituted,  the  foot  being  fixed  in  moderate  equinus  by 
a  cork  wedge  beneath  the  heel.  On  this  the  patient  is  encour- 
aged to  walk.  The  plaster  support  may  be  used  with  advantage 
for  six  months  or  a  light  brace  may  be  substituted  for  it. 
Eventually  the  brace  is  discarded  and  a  shoe  with  a  cork  inner 
55 


866  OETHOPEDIC   SUPiGEEY. 

sole  holding  the  foot  in  plantar  flexion  is  substituted.  If  all  the 
details  are  properly  carried  ont,  particularly  the  backward  dis- 
placement and  adjustment  of  the  malleoli,  the  result  is  a  sym- 
metrical foot,  a  movable  ankle-joint,  and  yet  a  secure  support 
that  eventually  enables  the  patient  to  dispense  with  the  brace. 

Fig.  .592. 


An    X-ray    picture    after    the    author's    operation    demonstrating   the    mechanical 
prevention  of  both  lateral  and  anteroposterior  deformity.     See  Fig.  58(5. 

ACQUIRED  CALCANEOVALGUS  AND  CALCANEOVAEUS. 

In  many  cases,  the  foot  deformed  as  a  result  of  paralysis  of 
the  calf  muscle  is  in  addition  turned  in  a  lateral  direction,  so 
that  the  weight  of  the  body  falls  to  the  inner  or  outer  side  of  its 
centre  (Fig.  593). 

Calcaneovalgus,  in  which  the  foot  is  turned  outward  and 
upward,  so  that  the  patient  walks  on  the  inner  side  of  the  heel 
or  even  on  the  inner  ankle,  is  by  far  the  most  common.  It  is 
usually  a  result  of  more  extensive  paralysis  than  simple  cal- 
caneus. For  example,  all  the  muscles  about  the  foot  may  be 
disabled  except  the  peronei.  or  in  cases  of  a  milder  type  the 
tibialis  anticus  may  be  the  only  muscle  of  the  front  of  the  foot 
that  is  paralyzed. 

Treatment. — When  the  foot  inclines  toward  calcaneovalgus  it 
is  diflicult  to  hold  it  in  proper  position  by  the  ordinary  braces. 
A  more  efficient   support   is   shown   in   Fig.    59-i.      A  plaster 


DEFORMITIES  OF  THE  FOOT. 
Fig.  593. 


867 


Talipes  calcaneovalgus  showing  the  characteristic  distortion  and  atrophy  of  the 
foot  and  leg.     A  type  of  deformity  in  which  the  author's  operation  is  indicated. 

cast  of  the  leg  with  the  foot  in  a  moderate  degree  of  plantar 
flexion  is  made  and  on  it  the  lines  for  the  brace  are  drawn 
The  sole-plate  encloses  the  foot,  ris- 
ing on  the  outer  border  to  a  somewhat 


Fig.  594. 


less  degree  than  on  the  inside. 


The 


uprights  are  riveted  to  the  foot-plate 
and  are  joined  bj  a  padded  metal 
band  just  below  the  tibial  tubercle, 
the  circumference  being  completed  by 
a  strap.  The  shoe  is  adjusted  to  the 
brace  by  means  of  a  cork  wedge. 

Calcaneovarus  is  a  much  less  seri- 
ous affection,  since  the  foot  may  be 
more  easily  supported.  A  brace, 
such  as  is  used  in  the  treatment  of 
ordinary  varus,  without  motion  at  the 
ankle  or  provided  with  a  reverse  stop, 
is  ordinarily  employed.  The  author's 
operation  is  especially  indicated  for 
confirmed  calcaneus  deformity  of  the 
valgus  or  varus  type.  It  has  been 
performed  by  the  writer  in  more  than 
50  cases  during  the  past   10  years. 


A  brace  for  calcaneovalgus  or 
varus. 


868  OBTHOPEDIC  SUBGEBY. 

It  has  displaced  all  other  operative  and  mechanical  treatment 
of  confirmed  deformity  and  even  in  early  cases  it  maybe  selected 
as  a  conservative  treatment. 

ACQUIRED   TALIPES   EQUINOVARUS. 

Talipes  eqninovarus  is,  in  the  acquired  as  in  the  congenital 
form,  the  most  common  of  the  deformities  of  the  foot  (Fig. 
577). 

The  tendency  of  simple  eqninus  is  usually  toward  varus,  be- 
cause in  plantar  flexion  the  foot  is  slightly  adducted  and  because 
the  outer  side  of  the  foot  is  shorter  than  the  inner  side,  so  that 
in  walking  with  the  foot  extended  the  tendency  of  the  foot  is  to 
turn  somewhat  inward.  Eqninovarus  is  usually  preceded  by 
eqninus,  and  the  etiology  of  the  one  will  serve  for  the  other 
(page  849). 

In  certain  cases  the  varus  is  more  marked  than  the  eqninus, 
as,  for  example,  when  the  abductors  of  the  foot  are  paralyzed 
while  the  adductors  retain  their  power ;  or  in  cases  of  direct  in- 
jury, as  in  fracture  at  the  ankle ;  or  when  the  growth  of  the  tibia 
has  been  arrested,  as  the  result  of  injury  or  disease. 

A  detailed  account  of  the  appearance  aiSd  effect  of  the  de- 
formity is  unnecessary. 

Treatment. — If  the  deformity  is  resistant  it  should  be  re- 
duced and  overcorrected  by  forcible  manipulation  under  anses- 
thesia.  Division  of  resistant  parts  is  less  often  necessary  than 
in  the  congenital  form,  but  it  may  be  required  in  neglected  cases. 
The  overcorrected  position  should  be  retained  until  time  has 
been  allowed  for  the  recontraction  of  the  lengthened  tissues ;  for, 
as  has  been  mentioned  in  the  treatment  of  eqninus,  overcorrec- 
tion and  rest  is  by  far  the  most  effective  treatment  that  can  be 
applied  to  a  weak  or  paralyzed  part.  The  foot  must  then  be 
supported  by  a  brace,  of  which  the  Taylor  club-foot  apparatus 
is  the  type  (Fig.  543). 

Astragalectomy  and  cuneiform  osteotomy  are  rarely  indi- 
cated, but  the  latter  operation  is  sometimes  of  service  in  check- 
ing the  tendency  toward  recurrence  of  deformity,  which  is  more 
persistent  after  overcorrection  in  the  paralytic  than  in  the  con- 
genital talipes. 

Transplantation  of  half  of  the  tendon  of  the  tibialis  anticus 
tendon  to  the  periosteum  or  bone  of  the  outer  border  of  the  foot, 


DEFOBMITIES  OF  THE  FOOT.  869 

combined  with  arthrodesis  of  the  astragalo-naviciilar  articula- 
tion in  an  attitude  of  slight  abduction,  is  of  service  as  a  curative 
procedure.     (See  Tendon  Transplantation.) 

Fig.  595. 


A  brace  for  equinovalgus  deformity.     The  author's  brace  for  weak  foot  combined 
with  an  upright  with  a  stop  joint  to  prevent  plantar  flexion. 


ACQUIRED  TALIPES  EQUINOVALGUS. 

Acquired  talipes  equinovalgus  is  much  less  frequent  than  the 
preceding  deformity.  Simple  equinovalgus  is  usually  the  result 
of  primary  paralysis  of  the  tibialis  anticus,  the  most  powerful  of 
the  dorsal  flexors ;  thus  the  foot  is  drawn  somewhat  outward 
when  dorsiflexed,  while  the  metatarsal  bone  of  the  great  toe, 
having  lost  the  proper  support  of  the  paralyzed  muscle,  falls 
downward  and  is  drawn  outward  by  the  peroneus  longus.  In 
this  type  one's  attention  is  often  attracted  by  the  peculiar  ap- 
pearance of  the  great  toe,  which  is  deformed  somewhat  like  a 
hanuner-toe  by  the  overaction  of  the  extensor  longus  hallucis  in 
its  attempt  to  take  the  place  of  the  tibialis  anticus.  The  equinus 
is  usually  slight  and  is  secondary  to  the  valgus.  Treatment  may 
be  begun  by  placing  the  foot  in  a  plaster  bandage  in  an  attitude 
of  varus  and  allowing  the  patient  to  walk  upon  it  until  the 
tendency  toward  deformity  has  been  overcome.  A  support  with 
the  catch,  as  for  toe-drop,  is  applied  to  the  shoe,  and  the  tendency 
toward  valgus  is  checked  by  raising  the  inner  border  of  the  sole 
or  by  the  use  of  a  sole  plate,  as  in  the  treatment  of  the  simple 


870  OBTHOPEDIC   SUEGEET. 

weak  foot  (Fig.  495),  In  this  class  of  cases  tendon  transplan- 
tation, particnlarlv  the  implantation  of  the  tendon  of  the  exr 
tensor  longns  hallueis  in  the  region  of  the  navicular,  combined 
with  arthrodesis  of  the  astragalonavicular  articulation  to  fix  the 
foot  in  the  attitude  of  adduction  is  indicated. 

ACQUIRED  SIMPLE  TALIPES  VALGUS. 

•  Acquired  simple  talipes  valgus  from  paralysis  of  both  the 
tibialis  anticus  and  posticus  is  rare.  Talipes  valgus,  in  combi- 
nation with  cavus,  caused  by  complete  paralysis  of  the  leg 
muscles,  is  an  occasional  variety  of  dangie-foot. 

Talipes  valgus,  sometimes  called  spurious  valgus,  the  simple 
weak  or  flat-foot,  has  been  described  elsewhere.     (Chapter  XX.) 

Talipes  caused  by  cerebral  disease,  whether  of  the  paraplegic 
or  the  hemiplegic  type,  is  in  early  childhood  almost  always  of 
the  form  of  equiuovarus.  In  adolescence  the  deformity  may  be 
equinovalgus  or  even  calcaneovalgus  if  there  is  extreme  flexion 
at  the  knee.  The  hemi^Dlegic  form  of  talipes  is  much  more  rigid 
and  unyielding  than  the  paraplegic  type.  The  treatment  of 
spastic  paralysis,  of  which  the  deformity  is  a  part,  is  discussed 
elsewhere.  (Chapter  XYIII.)  The  deformity  must  be  cor- 
rected by  the  ordinary  methods.  In  many  instances  when  the 
contractions  are  not  marked  mechanical  treatment  is  unneces- 
sary. 

Traumatic  valgus  and  equinovalgus  caused  by  fracture  at  the 
ankle  (Pott's  fracture)  may  be  treated  by  osteotomy  of  the  tibia 
above  the  ankle.  By  this  means  the  proper  relation  of  the  leg 
to  the  foot  may  be  restored  in  many  instances.  Equinovalgus 
of  slight  degree  is  not  uncommon  after  tuberculosis  or  rheuma- 
toid disease  at  the  ankle  or  at  the  astragalonavicular  joints. 
This  is  practically  one  variety  of  weak  foot. 

Hysterical  equinovarus  or  other  form  of  deformity  is  not  espe- 
cially rare.  The  diagnosis  may  be  made  from  the  other  symp- 
toms of  hysteria,  from  the  history  of  the  onset  and  duration  of 
the  distortion,  and  from  the  appearance  of  the  deformity,  which 
is  evidently  merely  an  assumed  posture.     (See  page  667.) 

TENDON  TRANSPLANTATION. 

When  one  or  more  of  the  muscles  are  paralyzed  the  unbalanced 
action  of  the  others  tends  to  distort  the  foot.     The  object  of 


DEFORMITIES  OF  THE  FOOT. 


871 


tendon  or  muscle  transplantation  is  to  utilize  the  muscular 
power  that  remains  to  the  best  advantage.  Thus  a  muscle  which 
only  serves  to  distort  the  foot  may  be  transplanted  to  a  point 
where  it  may  restrain  deformity  and  improve  functional  ability. 

Tendon  Transplantation. — Tendon  transplantation  was  first 
performed  by  Xicoladoni  in  1882^  for  the  relief  of  paralytic 
calcaneus.  The  tendons  of  the  peroneus  longus  and  brevis  were 
divided  behind  the  external  malleolus,  and  the  proximal  ends 
united  to  the  distal  extremity  of  the  divided  tendo  Achillis. 

The  first  operation  on  the  front  of  the  foot  was  performed  by 
Parish,^  of  Xew  York,  for  the  relief  of  paralytic  valgiis,  by 
sewing  the  tendon  of  the  extensor  projDrius  hallucis  to  that  of 
the  paralyzed  tibialis  anticus,  without  division  of  either  tendon. 
The  field  of  the  operation  has  since  been  extended  to  include 
almost  every  possible  combination  of  tendons  and  muscles.^ 

The  functions  of  the  muscles  and  their  relative  order  of  im- 
portance in  the  execution  of  each  movement  have  been  described. 
(Chapter  XX.)  They  are  indicated  in  the  following  table, 
modified  somewhat  from  that  of  Codivilla  : 


Dorsal 

Plantar 

Adduc- 

Abduc- 

Ever- 

Inver- 

flexion. 

flexion. 

tion. 

tion. 

sion. 

sion. 

Tibialis  anticus 

1 









1 

Extensor  proprius  hallucis 

3 

■    — 

— 

— 

— 

6 

"        longus  digitorum* 

2 

— 

— 

3 

3 

Peroneus  brevis 

— 

6 

— 

2 

2 

"         longus 

— 

3 

— 

1 

1 

Gastrocnemius  and  soleus 

— 

1 

2 

— 

— 

2 

Tibialis  posticus 

— 

4 

1 

— 

— 

3 

Flexor  longus  hallucis 

— 

2 

3 

— 

— 

4 

"           "      digitorum 

— 

5 

4 

— 

— 

5 

Time  for  Operation. — The  operation  should  not  be  undertaken 
until  the  degree  of  final  paralysis  has  been  determined.  This 
stationary  stage  may  be  reached  in  a  comparatively  short  time, 
but  in  the  ordinary  cases  in  which,  for  want  of  protection,  the 
part  has  become  distorted,  it  is  practically  impossible  to  esti- 
mate the  latent  muscular  power  until  the  deformity  has  been 
corrected,  and  until  the  enfeebled  muscles  have  been  stimulated 
by  functional  use.     In  general,  a  period  of  two  years  at  least 

^  Archiv  f .  klin.  Chir.,  1882,  iii.,  xxvii.,  S.  660. 

-  New  York  Medical  .Journal,  October  8,  1892. 

^  For  a  complete  bibliography  up  to  1902,  see  Vulpius,  Die  Sehneniiber- 
pflanzitng,  etc.,  Leipzig,  1902. 

pflanzung,  etc.,  Leipzig,  1902.     Also  Die  Behand.  d.  Spinal  Kinderlahmung, 
Leipzig,  1910. 

*  Including  peroneus  tertius. 


Fig.  596, 


Fig.  597. 


of  wl 
2/1 


GASTII 


lUS 


The    muscles    and    tendons    on    the  The    muscles    and    tendons    on    the 

front   of  the   leg.      (Testut,   from   Ger-        back    of   the   leg.      (Testut,    from    Ger- 
rlsh's  Anatomy.)  rish's  Anatomy.) 


DEFORMITIES  OF  THE  FOOT. 


873 


Fig.  598. 


should  intervene  between  the  onset  of  the  paralysis   and  the 
operation. 

The  first  essential  for  success  by  this  means  is  a  clear  under- 
standing of  the  mechanism  of  the  disabled  part  and  of  the  rela- 
tive importance  of  its  functions. 
As  regards  the  foot,  for  example, 
plantar  flexion  is  far  more  impor- 
tant than  dorsal  flexion,  because  the 
inability  to  plantar  flex  implies  the 
loss  of  the  principal  lifting  and  pro- 
pelling power  of  the  body.  Dorsal 
flexion  is  more  important  than  ad- 
duction or  abduction,  because  the 
drop-foot,  so-called,  interferes  seri- 
ously with  locomotion.  Adduction 
is  more  important  than  abduction, 
because  the  loss  of  power  to  turn 
the  foot  inward  induces  the  atti- 
tude of  valgus,  which  is  more  dis- 
abling and  more  difficult  to  remedy 
than  the  opposite  deformity.  To 
the  importance  of  these  movements 
the  power  of  the  muscles  corre- 
sponds.-^ 

Selection  of  Muscles. —  In  selecting 
muscles  for  transplantation  one  at- 
tempts usually  to  reduce  the  distort- 
ing power  as  well  as  to  replace  lost 
function.  For  example,  if  the  tibi- 
alis anticus  were  paralyzed  one 
would  naturally  replace  it  by  its 
adjunct,  the  extensor  hallucis.  This 
might  complete  the  operation,  or 
the  peroneus  tertius,  the  most  direct 
abductor  on  the  dorsal  surface  of 
the  foot,  might  be  divided  and  the 
proximal  end  attached  to  the  peri- 
osteum near  the  centre  of  the  foot,  or  the  peroneus  brevis  may 
be  changed  from  a  direct  to  an  indirect  abductor  by  dividing 
it  and  sewing  it  to  the  longus  to  further  assure  the  success  of  the 
operation. 

^  See  tables  ou  page  705. 


Tendons  in  the  right  sole. 
(Testut  from  Gerrish's  Anat- 
omy. ) 


874 


OETHOPEDIC   SUSGEEY. 


If,  on  the  other  hand,  the  dorsal  abductors  were  reduced  in 
strength  so  that  the  foot  turned  inward  in  dorsiflexion.  the 
tibialis  anticus  tendon  should  be  split,  from  its  insertion  to  the 
muscular  substance,  and  the  outer  half  carried  over  the  other 
tendons  and  fastened  securely  at  or  near  the  insertion  of  the 
peroneus  tertius  as  well  as  to  that  tendon;  thus  the  power  of 
adduction  would  be  weakened  and  that  of  abduction  increased. 

Fig.  599. 


Paralytic  equinovauus   before   operation.      (See  Fig.   600.) 

If  the  calf  muscle  is  paralyzed,  and  if  the  foot  is  inclined 
toward  valgus  iDecause  of  weakness  of  the  adductor  group,  the 
two  peronei  tendons  may  be  attached  at  the  insertion  of  the 
tendo  Achillis,  not,  of  course,  with  the  aim  of  rej)lacing  its  lost 
function  by  two  such  feeble  muscles,  but  because  the  power  no 
longer  inducing  deformity  might  become  functionally  useful  in 
preventing  deformity  and  become  of  some  functional  service, 
even  if  slight.     (See  Talipes  Calcaneus.) 

Paralysis  of  the  tibialis  posticus  muscle  may  be  treated  by 
dividing  the  peroneus  brevis  at  or  near  its  insertion,  passing  it 
beneath  the  tendo  Achillis  and  attachins;  it  to  the  tendon  of  the 


DEFOBMITIE.S  OF  THE  FOOT. 


875 


former.  It  may  be  mentioned,  also,  that  sections  of  the  tendo 
Achillis  have  been  used  to  strengthen  either  the  posterior  ad- 
ductors and  abdnctors.  As  has  been  stated,  one  must  plan  the 
operation  according  to  the  function  that  is  lost  and  the  power 
that  remains  and  combine  this  procedure  if  possible  with  others 
to  assure  the  desired  result.  As  a  rule,  the  most  successful 
operations  are  those  in  which  a  muscle  of  similar  function  to 
that  of  the  paralyzed  one  is  transplanted.  It  is  apparent,  also, 
that  it  will  be  of  little  use  to  transpose  a  muscle  unless  its  origin 
is  such  that  it  can  work  to  advantage  at  its  new  point  of  attach- 
ment.    For  example,  an  anterior  adductor  may  be  changed  to 

Fig.  600. 


Paralytic  equinovarus  cured  by  operation,  showing  power  of  dorsal  flexion 
(one-half  of  the  tendon  of  the  tibialis  anticus  attached  to  the  periosteum  of  the 
outer  border  of  the  foot).  Operation  July  19,  1898.  The  direct  union  of  tendons 
to  periosteum  at  the  most  advantageous  point  has  been  urged  especially  by  Lange 
(Ueber  Periostale  Schnenverplanzung  bei  Liihgmung,  Miinch.  med.  Woch.,  1900, 
No.  15). 


an  abductor,  and  the  function  of  a  posterior  adductor  or  abduc- 
tor can  be  similarly  transferred,  but  a  posterior  plantar  flexor  can 
never  be  efficient  as  a  dorsal  flexor ;  nor  can  one  muscle  act  as 
an  extensor  and  as  a  flexor  at  the  same  time,  as  would  appear  to 
be  the  belief  of  many  who  have  contributed  to  the  literature  of 
the  subject.  The  variety  of  combinations  of  this  character  that 
have  been  advocated  is  very  large,  but  it  is  hardly  necessary  to 
describe  them.     As  has  been  mentioned,  one  mar  alwavs  sacri- 


876  OETHOPEDIC  SURGEEY. 

fice  a  less  important  to  a  more  important  function,  and  as  a 
weak  muscle  can  hardly  carry  out  its  original  function  and  a 
more  important  one  as  well  it  is  advisable  in  most  instances  to 
relieve  it  completely  of  the  first  in  making  the  transfer. 

The  Operation. — The  technique  of  the  operation  is  simple.  All 
restriction  to  normal  motion  must  be  overcome  by  manual  force, 
and,  if  necessary,  by  tenotomy  as  a  preliminary  measure.  The 
operation  should  be  performed  under  an  Esmarch  bandage. 
The  incision  either  continuous  or  divided  should  expose  the 
muscular  substance  of  the  muscles  and  the  point  at  which  the 
transplanted  tendon  is  to  be  attached.  By  exposing  the  parts 
one  is  able  to  verify  the  previous  diagnosis.  A  completely 
paralyzed  muscle  is  atrophied  and  of  a  dull,  reddish-yellow 
color,  and  its  tendon  is  of  a  yellowish-white  tinge.  A  partially 
paralyzed  muscle  is  atrophied,  its  tendon  is  small,  but  it  retains 
the  silvery  glisten  of  the  normal  structure.  The  tendon  sheaths 
having  been  oj^ened,  the  tendon  is  divided  or  split  near  its  in- 
sertion, and  having  been  freed  from  any  restraint  that  might 
impair  its  direct  action  it  is  placed  in  apposition  to  the  tendon 
of  the  paralyzed  muscle,  whose  surface  has  been  freshened  with 
the  knife  or  better  it  is  passed  directly  through  it  and  its  ex- 
tremity is  sewed  to  the  periosteum  of  the  neighboring  bone. 
The  two  tendons  are  then  attached  to  one  another  by  several 
sutures  of  silk,  and  the  graft  is  covered  by  uniting  the  tendon 
sheath  or  fatty  tissue  over  it  with  fine  catgiit.  The  skin  incision 
is  closed  with  a  continuous  catgut  suture.  It  should  be  stated 
that  the  graft  is  ajjplied  under  a  certain  tension,  all  the  slack 
being  drawn  in,  as  it  were,  so  that  the  foot  is  held  if  possible  in 
the  normal  attitude.  This  is  further  assured  in  most  instances 
by  shortening  the  tendon  of  the  paralyzed  muscle.  A  plaster 
bandage  is  then  applied  in  the  overcorrected  position,  and  in 
this  attitude  the  foot  should  be  used  for  many  months. 

Modifications  of  the  Operation. — Since  its  introduction  the 
operation  of  tendon  transplantation  has  been  modified  in  several 
particulars.  It  has  been  demonstrated  by  experience  that  there 
is  a  strong  tendency  toward  relapse  to  the  original  deformity, 
because  of  weakness  of  the  transposed  muscle,  the  mechanical 
disadvantage  to  which  it  is  subjected  and  in  some  degree  because 
of  the  insecurity  of  its  attachment. 

Lange  was  the  first  to  urge  that  the  tendon  of  the  living 
muscle  should  not  be  attached  to  that  of  the  paralyzed  one,  but 
shonld   be    fixed   directl}'   to   the   periosteum    at    the    point    of 


DEFOEMITIES  OF  THE  FOOT. 


877 


greatest  mechanical  efficiency.  This  procedure  has  now  been 
generally  adopteel  or  at  least  the  tendinous  attachment  has 
become  supplemental  to  the  periosteal.  If  the  tendon  is  not 
long  enough  for  this  purpose  it  may  be  lengthened  by  means  of 
a  silk  cord.  By  this  means  the  scope  of  the  operation  has  been 
greatly  extended  both  in  the  applicability  to  the  foot  and  to 
other  parts  of  the  boely.  Lange  uses  strong  silk  ligatures  pre- 
viously boiled  in  a  solution  of  corrosive  sublimate  (1 — 1000). 
These  ai-e  dried  and  are  preserved  in  paraffine  which  lessen 

Fig.  601. 


Talipes  equinovalgus  after  treatment  by  tendon  transplantation.  The  tendon 
of- the  peroneus  tertius  was  attached  to  the  overlapped  and  shortened  tendon  of 
the  tibialis  anticus.  All  the  tendons  on  the  front  of  the  foot  were  then  united, 
so  that  all  might  serve  as  dorsal  flexors. 


the  danger  of  adhesion  with  the  surrounding  tissues.  The 
muscle  to  be  transferred,  for  example  the  peroneus  brevis,  to 
replace  the  tibialis  anticus,  is  exposed  by  a  long  incision.  It  is 
separated  in  the  greater  part  of  its  area  from  its  attachments, 
its  extremity  is  passed  beneafh  the  skin  and  is  drawn  through  an 
incision  in  the  line  of  the  tibialis  anticus.  To  it  the  silk  cord  is 
attached  by  quilting  it  through  its  substance.  A  free  channel  is 
then  made  directly  beneath  the  skin  to  an  incision  over  the 
scaphoid.     Through  this  the  silk  tendon  is  drawn  and  is  firmly 


878  OPiTEOFEDIC   SVFiGEF^Y. 

attached  to  the  periosteum  at  such  teusion  as  will  hold  the  foot 
inverted.     A  plaster  bandage  is  then  applied. 

Tendon  Transplantation  in  Combination  with  Other  Procedures — 
As  the  object  of  operative  treatment  is  to  prevent  deformity  and 
to  increase  the  stability  of  the  foot,  tendon  transplantation  may 
be  of  gTeater  service  when  combined  with  other  operations. 
One  of  these  has  been  mentioned  in  the  treatment  of  talipes  cal- 
caneus. (See  page  861.)  For  valgtis  deformity  arthrodesis  of 
the  astragalonavicular  articulation  is  a  valuable  adjunct  of 
tendon  transplantation.  An  incision  about  three  inches  in 
length,  long  enough  to  expose  the  muscular  substance  of  the 
extensor  longus  hallucis  and  the  astragalonavicular  articulation 
is  made.  This  joint  is  then  opened  and  the  cartilage  is  thor- 
oughly removed  from  the  adjoining  lx)nes.  The  -tibialis  anticus 
tendon  is  overlapped  and  shortened  and  the  tendon  of  the  pro- 
prius  hallucis  is  divided  and  is  sewed  with  silk  to  it  and  to  the 
inner  border  of  the  navicular  at  such  tension  as  to  hold  the  foot 
in  inversion.  The  ligament  covering  the  denuded  bones  is  then 
shortened  and  sewed  with  silk,  the  wound  is  closed  and  the  foot 
is  fixed  in  extreme  inversion  and  slight  dorsal  flexion  by  a 
plaster  bandage.  A  similar  procedure  is  employed  if  the  de- 
formity is  of  the  varus  type,  in  which  half  the  tibialis  anticus 
muscle  has  been  by  means  of  silk  cord  attached  to  the  outer 
border  of  the  foot.  A  thin  wedge  of  bone,  including  the  cal- 
caneocuboid and  the  outer  half  of  the  astragalonavicular  articu- 
lation, is  removed  from  the  dorsal  aspect  of  the  foot.  Forced 
abduction  closes  the  opening  and  continued  contact  is  assured  by 
several  heavy  silk  sutures. 

The  foot  should  be  retained  for  several  months  in  the  over- 
corrected  position  by  a  plaster  bandage,  on  which  the  patient 
walks  about  imtil  the  parts  have  thoroughly  conformed  to  the 
new  position,  the  aim  being  to  supplement  muscular  weakness 
by  a  fixed  attitude  or  slight  deformity  of  a  character  opposed 
to  that  for  which  the  operation  was  ^^erformed.  In  many  in- 
stances further  support  is  unnecessary,  but  a  brace  should  be 
used  if  there  is  a  tendency  toward  deformity.  Massage,  passive 
and  active  exercises  in  the  direction  opposed  to  deformity  are 
of  great  importance  in  after-treatment. 

The  prognosis  depends  upon  the  degree  of  permanent  paraly- 
sis and  its  distribution.  It  is,  of  course,  evident  that  tendon 
transplantation  is  essentially  a  palliative  rather  than  a  curative 
operation.    In  selected  cases  in  which  the  attachment  is  directly 


DEFORMITIES  OF  THE  FOOT.  879 

to  the  bone,  and  esjDecially  when  lateral  motion  is  checked  by 
arthrodesis,  the  results  are  very  satisfactory.  The  improvement 
in  functional  ability  is  immediately  shown  in  the  circulation 
and  size  of  the  limb.  In  some  cases  of  this  class  the  transferred 
muscle  ajDparently  undergoes  an  adaptive  hypertrophy. 

The  principles  of  tendon  transplantation  may  be  aj)plied  in 
other  situations.  For  example,  the  trapezius  may  replace  the 
deltoid  (page  645),  the  sartorius  or  the  tensor  vaginse  femoris 
muscle  may  be  attached  to  the  tendon  of  a  paralyzed  quadriceps 
extensor  muscle  for  the  purpose  of  restoring  in  some  degree  the 
ability  to  extend  the  leg  (page  647). 

The  flexor  muscles  may  be  transplanted  to  the  extensor  aspect 
of  the  thigh  to  overcome  persistent  contracture,  the  result  of 
spastic  paralysis  (page  659). 

The  operations  for  the  relief  of  hemijDlegic  deformity  of  the 
hand  have  been  mentioned  (page  657). 

Tendon  Splicing.- — Division  and  overlaj^ping  of  the  tendons  of 
paralyzed  muscles  may  be  employed  w^ith  advantage  in  certain 
instances.  For  example,  in  complete  paralysis  of  all  the  dorsal 
flexors  of  the  foot,  each  tendon  may  be  shortened  and  attached 
to  the  anterior  ligament ;  thus  the  toe-drop  may  be  remedied  or 
reduced  to  such  an  extent  that  the  deformity  may  interfere  but 
slightly  with  locomotion.  Silk  cords  passed  from  the  tibia  to 
the  tarsus  after  the  method  of  Lange  have  also  been  used  for 
this  purpose.  They  are  quilted  into  the  periosteum  of  the  tibia 
or  either  passed  directly  through  its  substance.  The  silk  is  then 
by  means  of  a  bodkin  passed  beneath  the  annular  ligament  and  is 
attached  in  the  neighboi'hood  of  the  navicular  and  cuboid  bones. 
The  silk  strands  are  eventually  enclosed  in  fibrous  tissue  and 
replaced  by  it.  As  a  temporary  support  the  silk  ligaments  may 
be  of  some  service.  As  a  rule,  however,  operations  of  this  class 
should  be  supplemented  by  arthrodesis  or  by  apparatus,  other- 
wise deformity  will  recur. 

Arthrodesis. — The  removal  of  the  cartilaginous  surfaces  of 
articulating  bones  to  induce  anchylosis  for  the  relief  of  par- 
alytic deformities  of  the  foot,  was  first  performed  by  Albert,  of 
Vienna,  in  1878.  As  applied  to  the  foot,  it  is  of  special  service 
in  those  cases  in  which  practically  no  muscular  jDower  remains, 
the  so-called  dangle-foot.  It  may  be  of  service,  also,  in  cases 
of  less  disability,  as  in  equinus  or  calcaneus,  if  the  patient  is 
unable  to  provide  himself  with  apparatus  or  desires  to  dispense 
with  it.     It  is  of  little  value  in  the  younger  class  of  patients  as 


880  OBTHOPEDIC   SUEGEBY. 

the  bones  are  not  sufficiently  developed  to  assure  adhesion. 
Eight  years  has  been  suggested  as  the  age  limit. 

The  operation  consists  in  opening  the  joint  and  removing  the 
cartilage  from  the  apposed  surfaces  of  the  bones,  then  fixing 
them  in  contact  by  nails  or  sutures  or  by  a  plaster  bandage 
until  union  has  taken  place.  If  the  case  is  one  of  simple  cal- 
caneus or  equinus,  without  lateral  deviation,  the  operation  may 
be  limited  to  the  ankle-joint,  v^hich  may  be  opened  from  the 
back,  front  or  side,  as  seems  preferable.  As  has  been  stated,  the 
usual  incision  is  about  two  inches  in  length  over  the  front  of 
the  ankle-joint.  The  foot  is  then  plantar  flexed  and  the  cartilage 
is  thoroughly  removed  from  the  articulating  surfaces  with  a 
thin  chisel  or  knife.  The  lateral  incision  as  used  for  the  removal 
of  the  astragalus  with  inward  displacement  of  the  foot  permits 
a  more  thorough  inspection  of  the  joint  and  in  many  instances 
it  is  to  be  preferred.  As  the  removal  of  the  cartilage  at  the 
ankle-joint  increases  its  capacity  and  thus  prevents  accurate 
ap23osition,  Farrabeuf  and  Goldthwait  divide  the  fibula  above 
the  articulation  so  that  it  may  be  forced  against  the  astragalus. 
If  lateral  deformity  is  present  the  subastragalar  joints  are  de- 
stroyed and  by  prolonging  the  lateral  incision  over  the  dorsum 
of  the  foot  the  mediotarsal  may  be  reached.  As  a  rule,  in  cases 
of  complete  paralysis  of  the  anterior  group  simple  anchylosis  at 
the  ankle-joint  is  not  sufficient  to  prevent  the  toe-drop,  and  it  is 
well  to  destroy  the  mediotarsal  joint  also.  A  convenient  method 
.is  to  remove  the  cartilaginous  surface  of  the  astragalonavicular 
and  calcaneocuboid  articulations,  together  with  a  thin  wedge  of 
bone,  base  uppermost.  In  some  instances  the  tendons  of  the 
paralyzed  muscles  are  shortened  to  aid  in  retaining  the  foot  in 
the  improved  position.  This,  however,  is  of  minor  importance. 
The  operation  should  be  performed  under  the  Esmarch  bandage, 
and  the  limb  should  be  elevated  for  a  time  to  prevent  the  subse- 
quent bleeding  from  the  bones. 

The  improvement  in  the  gait,  obtained  by  the  rectification  of 
deformity,  and  by  fixation  of  the  foot,  after  arthrodesis,  is  often 
very  marked.  In  many  instances  though  bony  anchylosis  is  not 
attained  the  limitation  of  movement  is  sufficient  to  restrain 
deformity  and  to  permit  the  patient  to  discard  apparatus. 

Arthrodesis  is  also  performed  at  the  knee  and  at  the  elbow 
and  wrist- joints  for  the  purpose  of  fixing  the  part  in  a  use- 
ful attitude.  It  is  more  satisfactory  to  the  older  than  the 
younger  class  of  patients,  because  the  liability  to  recurrence  of 


DEF0BMITIE8  OF  THE  FOOT.  881 

deformity  is  less.  Arthrodesis  at  the  shoulder-joint  is  of  service 
when  the  humeroscapular  muscles  are  paralyzed,  especially  in 
those  cases  in  which  the  muscles  that  move  the  scapula  retain 
their  power,  since  anchylosis  adds  to  the  effectiveness  of  the  arm 
muscles.  The  joint  may  be  opened  by  an  incision  along  the 
anterior  lower  border  of  the  deltoid  muscle.  The  cartilaginous 
surfaces  are  removed,  and  the  humerus  is  then  fixed  in  close 
contact  with  the  glenoid  surface  of  the  scapula  by  a  drill  or  by 
sutures  until  union  is  firm.  In  most  instances,  however,  the 
transplantation  of  the  trapezius  muscle  is  to  be  preferred  if  it 
retains  its  power. 


56 


INDEX. 


Abduction,  forcible,  in  treatment  of 
coxa  vara,  583 
of  fracture   of   neck  of  the  fe- 
mur, 587 
Abnormalities  of  clavicle,  ^34 
of  ribs,  232 

persistent,  in  weak  foot,  722 
Abscess,  complicating  Pott's  disease, 
29 
pelvic,  in  tuberculous  disease  of 

spine  of  lower  region,  45 
in    tuberculous    disease    of    the 
hip-joint,  387 
significance  of,  388 
treatment  of,  389 
in  tuberculous  disease  of  knee- 
joint,  438 
treatment  of,  438 
Absence  of  clavicle,  234 
of  patella,  457 
of  ribs,  234 
of  vertebrae,  232 
Achillobursitis,  761 
anterior,  761 
etiology  of,  762 
pathology  of,  763 
posterior,  764 
symptoms  of,  762 
treatment  of,  763 
operative,  764 
Achillodynia,   761     (see    Achillobur- 
sitis) 
Achondroplasia    (see  Chondrodystro- 

phia,  526) 
Acquired  cerebral  paralysis  of  child- 
hood, 650 
displacement  of  patella,  457 
genu  recurvatum,  454 
etiology  of,  454 
treatment   of,   455 
luxation  of  clavicle,  237 
talipes,  788,  847 

calcaneovalgus,  866 

treatment  of,  867 
calcaneovarus,  867 

treatment  of,   867 
calcaneus,  857 

deformity   in,   develop- 
ment of,  858 
etiology  of,  858 
symptoms  of,  858 
treatment  of,  858 


Acquired    talipes,    calcaneus,    treat- 
ment of,  Judson 
brace  in,  859 
operative,  860 
Whitman 's    opera- 
tion in,  863 
Willett  's        opera- 
tion in,  861 
deformity    in,    development 

of,  814 
diagnosis     of,     differential, 
from    congenital    talipes, 
849 
equinovalgus,  869 

treatment  of,  869 
equinovarus,  867 

treatment  of,  868 
equinus,  849 

etiology  of,  850 
simple  valgus,  870 
symptoms   of,   851 
treatment   of,   852 

arthrodesis  in,  856 
immediate     correc- 
tion  of   deform- 
ity in,  853 
manipulation       in, 

853 
Shaffer     extension 
shoe  in,  853 
etiology  of,  847 
torticollis,  676 
Acromegalia,  834 

diagnosis  of,  535 
Actinomycosis  of  spine,  130 
Active   congestion,   in   treatment   of 

joint  disease,  264 
Acute  anterior  poliom.yelitis,  624 
epiphysitis  at  hip-joint,  410 
infectious  arthritis  of  hip-joint, 

410 
osteomyelitis,  280 
suppurative  arthritis  in  infancy, 

277 
synovitis  of  the  knee,  446 
tenosynovitis       at       wrist- joint, 

497 
tuberculous  arthritis,  279 
Adolescents,  kyphosis  of,  140,  226 
Adults,     traumatic     coxa     vara     in, 
588 
tuberculous  hip-disease  in,  386 


883 


884 


INDEX. 


Amputation,  in  treatment  of  tuber- 
culous   disease    of   knee-joint, 
442 
in    tuberculous    disease    of    Mp 
joint,  396 
Anchylosis,  298 

etiology  of,  299 
pathology  of,  299 
prevention  of,  299 
treatment  of,  299 

forcible  correction  in,  301 
operative  exploration  in,  802 
passive  motion  in,  299 
Ankle,  sprain  of,  473 
chronic,   476 
etiology  of,  473 
strapping  in,  474 
symptoms,  473 
treatment,    473 
Ankle-joint,  injuries  of,  473 
swelling  about  the,  480 
tenosynovitis  at,  478 
treatment  of,  479 
tuberculous,  479 
tiiberculosis  of,  463 

age  at  incipiency  of,  464 
astragalonavicular      disease 

in,  467 
deformity  in,  466 

reduction  of,  469 
diagnosis  of,  467 
etiology  of,  464 
pathology  of,  463 
physical      examination      in, 

466 
prognosis  in,  471 
situation    of,   464 
statistics  of,  463 
subastragaloid     disease     in, 

467 
symptoms  of,  465 
treatment  of,  469 
operative,  470 
Ankles,  swelling  about,  480 
Anterior  curvature  of  tibia,  621 
dislocation  at  hip-joint,  545 
displacement  of  tiljia,  455.    {See 
Genu  recurvatum,  congenital) 
metatarsalgia,  753 
poliomyelitis,   acute,   624 

age  at  onset  in,  625 
deformities  of  neck  in, 

633 
deformity  in,  631 
causes  of,  631 
reduction  of,  643 
secondary,  635 
of  trunk  in,  633 
of    upper    extrem- 
ity, 633 
diagnosis  of,  628 


Anterior   poliomyelitis,    acute,    diag- 
nosis    of,     from 
diphtheritic  par- 
alysis, 629 
from  joint  disease, 

628 
from  multiple  neu- 
ritis, 629 
from       obstetrical 

paralysis,   629 
from    other   forms 
of  spinal  paral- 
ysis, 628 
from   paralysis   of 
cerebral      origin 
in  childhood,  628 
from  Pott's  para- 
plegia, 628 
from  pseudo-paral- 
ysis, 629 
from     rheumatism 
and     j  oint     dis- 
ease, 628 
from  silastic  spinal 
paralysis,  628 
etiology  of,  625 
paralysis    of    different 
muscles  in,  effect 
of,    upon    fune- 
•  tion  of,  631 
distribution  of,  626 
pathology  of,  624 
prognosis  in,  630 

electrical    test    in, 
630 
retardation    of    growth 

in,  635 
symptoms  of,  626 
treatment  of,  636 

mechanical,     prin- 
ciples of,  637 
operative,  643 
of  paralysis  of  an- 
terior muscles  of 
the  leg,  637 
of  paralytic   scoli- 
osis, 642 
of    posterior    mus- 
cles   of    the 
leg,  637 
of  arm,  642 
of  muscles  of 
the  hip,  640 
of    thigh    muscles, 
63S 
Antero-posterior  contour  of  spine  in 
lateral  curvature,  155 
deformities  of  si>ine,  224 
kyphosis.  224 

symptoms  of,  227 
treatment    of,   227 
lordosis,  229 

treatment   of,  230 


INDEX. 


Aran-Duehenne   type   of   progressive 

muscular  atrophy,  661 
Arborescent     synovial     tuberculosis, 

256 
Arm,  paralysis  of,  obstetrical,  498 

treatment  of,  499 
Arthrectomy  in  treatment  of  tuber- 
culous disease  of  knee-joint,  439 
Arthritis,   atrophic,  287 
etiology  of,  290 
treatment  of,  291 
complicating       infectious       dis- 
eases, 276 
prognosis  in,  277 
treatment    of,   276 
deformans,  282 

hypertrophic,  283 
etiology  of,  285 
]3athology   of,  286 
symptoms  of,  286 
treatment  of,  287 
gonorrheal,  273 

distribution   of,   273 
in   infancy,   276 
symptoms  of,  274 
treatment   of,  275 
varieties  of,  274 
of  hip-joint,  acute,  symptoms  of, 
410 
treatment  of,  410 
gonorrheal,   411 
subacute,  411 
in   infancy,   277 

etiology  of,  277 
prognosis  in,  278 
sex  in,  277 
symptoms,  278 
treatment,  278 
puerperal,  276 
rheumatoid,  282 
of  spine,  infections,  132 
Still 's  form  of,  289,  290 
of  suboccipital  region  of  spine, 

133 
suppurative.     (See  Acute  arthri- 
tis of  infancy),  277 
tuberculous,  acute,  279 
Arthrodesis,  647 

in  paralytic  talipes,  879 
in  treatment  of  acquired  talipes 
calcaneus,  863 
equinus,  856 
Arthrotomy,    in    congenital    disloca- 
tion of  the  hip,  564 
Articulation,    sacro-iliac,    injury    of, 

148 
Articulations    of     upper    extremity, 

diseases  and  injuries  of,  481 
Astragalectomy  in  treatment  of  ne- 
glected talipes,  833 
Astragalonavicular  disease,  467 


Asymmetrical  develoi:)ment  of  body, 

238 
Ataxia,  hereditary,  663 
Atrophic  arthritis,  287 
etiology  of,  290 
treatment  of,  291 
Atrophy,  of  bone,  245 

muscular,  myelopathic  form  of, 
661 
progressive,  661 
in    tuberculous    disease    of    the 
hip-joint,  320 
causes  of,  314 
statistics  of,  325 
Attitude,   change   in,   in   Pott's   dis- 
ease, 28 
rachitic,  142,  523 
in  treatment  of  weak  foot,  729 
in  tuberculous   disease  of  spine 
in  lower  region,  39 


Back,  flat,  224 

hollow  round,  224 
round,  223 

knee,  454  (see  Genu  recurvatum) 
pain  in  lower  portion  of,  144 
treatment  of,  144 
Bandage,    plaster,    of    hip- joint,    of 
spine    (see    Spicas,    plas- 
ter jackets,  etc.) 
in    treatment     of    tubercu- 
lous disease  of  knee-joint, 
429 
Baseball  finger,  515 
Beck's    preparation    in    tuberculous 

disease  of  bones  and  joints,  263 
Bier's  treatment  of  tuberculous  dis- 
ease  of   the   knee-joint,    436    {see 
also  Bier's  hypereemia,  264) 
Bilateral  coxa  vara,  581 

dislocation  at  the  hip-joint,  544 
hip  disease,  384 
Billroth  splint,  in  treatment  of  tuber- 
culous   disease    of   the   knee-joint, 
430 
Body,  asynunetrical  development  of, 
238 
lateral  inclination  of,  in  tuber- 
culous   disease    of    spine    of 
lower  region,  41 
Bone,  atrophy  of,  245 

hypertrophy  of,  246 
Bones   and   joints   of   the  lower   ex- 
tremity, deformities  of,  594 
operation    on,    in    treatment    of 

neglected  talipes,  833 
tuberculous  disease  of,  247 
Bow-leg,  594 

anterior,  621 

symptoms  of,  621 


886 


INDEX. 


Bow-leg,  anterior,  treatment  of,  623 
attitude  of  rest  in,  597 
deformity   in,   measurement    of, 
618 
outgrowth  of,  597 
predisposition  to,  595 
symptoms  of,  617 
time  of  onset  of,.  595 
treatment  of,  618 
by  braces,  618 
expectant,  618 
operative,  620 
Brace,  anterior  shoulder,  94,  98 

caliper,   in   treatment   of  tuber- 
culous  disease    of   knee-joint, 
435 
Griffiths',    in     displacement    of 

semilunar  cartilage,  450 
Judson's,    in    treatment    of    ac- 
quired talipes  calca- 
neus, 859 
of    infantile    club-foot, 
806 
Knight  spinal,  219 
in  lateral  curvature  of  the  spine, 

219 
retention,    in    treatment    of    in- 
fantile club-foot,  810 
Taylor,   in  treatment   of  infan- 
tile  club-foot,   812 
of  Pott 's  disease,  93 
Thomas'  knee,  in  treatment  of 
tuberculous     disease     of     the 
knee-joint,  432 
in  treatment  of  bow-leg,  618 
of  infantile  club-foot,  806 
of  knock-knee,  610 
of     lateral     curvature     of 
spine,  219 
Whitman's,     in     treatment     of 
weak-foot,  734 
Brachial    plexus,    obstetrical    injury 

to,  repair  of,  503 
Bunion,  776 

Bursa,  pretibial,  enlargement  of  su- 
perficial, 453 
Bursas  and  cysts  in  popliteal  region, 

453 
Bursitis,   gluteal,  413 
iliopsoas,  413 

treatment  of,  414 
prepatellar,  452 

treatment,  452 
pretibial,  452 

symptoms,  452 
treatment,  453 
at  shoulder-joint,  chronic,  496 
treatment   of,  414 

C 

Calcaneobursitis,  765 
treatment  of,  765 


Calot  's  fluids  in  treatment  of  tuber- 
culous disease  of  bones  and  joints, 
263 
Calot  jacket,  83 

application  of,  to  patients  who 
have   been   treated   on   a 
stretcher  frame,  90 
in  recumbent  posture,  87 
Caput  quadratum  in  rachitis,  521 
Carcinoma  of  femur,  414 

of  spine,  128 
Caries,  dry,  258 

sicca,  258 
Cerebral  paralysis  of  childhood,  650 
acquired,    651 

after        birth, 

651 
deformities 

in,  655 
disability     in, 

655 
loss  of  growth 

in,  655 
paralysis      in, 
654 
congenital,   650 
deformities 

in,  654 
mentality    in, 

654 
paralysis      in, 

653 
weakness      in, 
653 
deformities  in,  654 
distribution  in,  650 
of  intrauterine  or- 
igin, 651 
occurring      during 

labor,  651 
paralysis  of  child- 
hood,      etiology 
of,  650 
pathology  of,  650 
prognosis  in,  660 
symptoms  of,  gen- 
eral, 652 
treatment  of,  656 
Cervical  opisthotonos,  692 

ribs,  232 
Charcot's   disease,   296 
diagnosis  of,  297 
distribution  of,  297 
I^athology  of,  296 
symptoms  of,  297 
treatment   of,  298 
Chest,  deformities  of,  234 
minor,   236 
flat,  234 

treatment  of,  235 
funnel,  236 
pigeon,  235 


INDEX. 


887 


Chest,  pigeon,  treatment  of,  236 
Childhood,     cerebral     paralysis     of, 
650 
osteomalacia  in,  530 

treatment  of,  531 
strains  and  injuries  of  knee  in, 

446 
weak  foot  in,  724 
Chondrodystropliia,   526 
etiology  of,  527 
pathology,  527 
prognosis  in,  528 
treatment  of,  528 
Clavicle,  absence  of,  234 

acquired  luxation  or  subluxation 
of,  237 
treatment  of,  237 
defective  formation  of,  234 
Club-foot,  congenital,  788 
anatomy  of,  795 
etiology  of,  789 
symptoms  of,  799 
statistics  of,   793 
treatment  of,  800 
Club-hand,  511 

etiology  of,  511 
statistics  of,  512 
treatment  of,  513 
varieties  of,   511 
Compensatory   deformity,   in   lateral 
curvature  of  spine,  165 
in  Pott's  disease,  28 
Congenital    and    acquired    affections 
leading  to  general  distortions, 
519 
cerebral  paralysis  of  childhood, 

650 
contraction  of  fingers,  514 

at  knee,  462 
deficiency  of  foot,  844 
deformities  of  elbow,  507 

of  foot,  associated  with  de- 
fective  development,   842 
at  knee,  461 

snapping  knee,  461 

treatment   of,   462 
at  wrist,  510 
dislocation  at  hip-joint,  536 
anterior,  545 

symptoms  of,  544 
bilateral,  544 
diagnosis  of,  545 
etiology  of,  541 
pathology  of,  537 
supracotyloid,  545 
symptoms  of,  542 
general,  544 
statistics  of,  536 
treatment  of,  547 

arthrotomy  in,  564 
in   infancy,   558 


Congenital    dislocation   at   hip-joint, 
treatment        of, 
Lorenz  's    opera- 
tion in,  548 
prognosis  in,  561 
in  older  subjects,  563 
open  operation  in,  565 
osteotomy  in,  565 
palliative,   571 
jireliminary  traction  in, 

552 
reduction  in,  551 
review  of,  568 
variations  in,  559 
at  shoulder,  498 
unilateral,  542 

symptoms  of,  542 
displacement  of  the  patella,  457 

of  phalanges,  514- 
elevation  of  the  scapula,  230 

etiology   of,    232 
genu  recurvatum,  455 
etiology,  456 
treatment  of,  457 
hypertrophy  of  the  foot,  844 
oedema  of  feet,  846 
subluxation  of  the  hip,  571 
talipes,  788 

caleaneovalgus,  842 
calcaueovarus,  842 
calcaneus,  840 
equinocavus,   842 
equinovalgus,    841 
equinus,  840 
etiology  of,  789 
valgocavus,   842 
valgus,  841 
varus,  839 
torticollis,  672 

etiology  of,  674 
pathology  of,  676 
weakness    in    cerebral    paralysis 
of  childhood,  653 
Constricting  bands  of  the  foot,  845 
Contracted  foot,  748 

etiology  of,  748 
symptoms  of,  749 
treatment  of,  751 
operative,  752 
Contraction,  Dupuytren  's,  516 
etiology  of,  516 
pathology   of,  516 
symptoms  of,  516 
treatment  of,  517 
at  knee,  congenital,  462 
psoas,  in  tuberculous  disease  of 
the  spine  in  the  lower  region, 
40 
Coxa  valga,  592 
vara,  572 

bilateral,  577 

deformity    in,     mechanical 
predisposition  to,  574 


INDEX. 


Coxa  vara,  diagnosis  of,  579 
etiology  of,  573 
other  varieties  of,  578 
pathology  of,  572 
symptoms  of,  575 

mechanical  effects,  575 
physical  effects,  577 
traumatic,  585 

in  adult  life,  589 
diagnosis  of,  586 
treatment   of,  588 
treatment  of,  581 
operative,  582 
Cramp,  muscular,  of  leg,  446 
Craniotabes  in  rachitis,  521 
Crepitus,  scapular,  236 
Cretinism,  527 
Cubitus  valgus,  508 

in  rachitis,  522 
varus,  508 

in  rachitis,  522 
Cuneiform  osteotomy  in  treatment  of 
anterior  bow-leg,  623 
of  coxa  vara,  583 
of  knock-knee,  614 
of     neglected     talipes, 
834 
Curvature  of  spine,  lateral,  149 
Cysts,  bursas  and,  in  popliteal  region, 
453 
of  femur,  414 


Defect  of  the  clavicle,  234 
Deformity  in  acquired  talipes,  devel- 
opment of,  848 
in   acute   anterior   poliomyelitis, 
633 
causes  of,   631 
reduction  of,  643 
secondary,  635 
of  bones  of  the  lower  extremity, 

594 
in  bow-leg,  measurement  of,  618 
outgrowth  of,  597 
jjredisposition  to,  595 
in   cerebral   paralysis    of    child- 
hood,  654 
of  chest,  234 
flat,  234 
funnel,  236 
minor,  236 
pigeon,  235 
compensatory,   in   lateral   curva- 
ture of  the  spine,  165 
in  Pott 's  disease,  29 
correction  of,  by  femoral  osteot- 
omy in  tuberculous  disease  of 
the  hip-joint,  399 
in  coxa  vara,  mechanical  predis- 
position to,  574 


Deformity,    development    of,    in    ac- 
quired talipes,  848 
calcaneus,  858 
of  elbow,  congenital,  507 
of  foot,  694,  785 

'compound,  786 
functional  pathogenesis  of,  240 

Wolff 's  law  of,  240 
hysterical,  664 
at  knee,  congenital,  461 
contraction,    462 
general,  462 

prognosis,  462 
treatment  of,  462 
snapping,  461 

treatment,  462 
in  knock-knee,  measurement  of, 
607 
outgrowth  of,  597 
predisposition   to,   595 
secondary,  604 
time  of  onset  of,  595 
in  lateral  curvature  of  spine,  165 
prevention  of,  180 
varieties   of,   172 
of  legs  with  weak  foot  in  child- 
hood,  726 
and  malformations  of  the  knee, 

456 
of  neck,  in  acute  anterior  polio- 
myelitis, 633 
of  other  parts  caused  by  tuber- 
culous    disease     of    the    hip- 
joint,  407 
overcorrection  of,  in  torticollis, 

684 
in  Pott 's   disease,  17 
compeusatorj',  29 
muscular,  28 
rapid  correction  of,  in  treatment 

of  neglected  talipes,  814 
rectification  of,  in  treatment  of 

infantile  tailzies,  801 
reduction   of,  in  congenital  dis- 
location of  shoulder,  498 
in  resistant  cases  of  tuber- 
culous disease  of  the  hip, 
398 
in  treatment  of  tuberciilous 
disease  of  the  knee-joint, 
428 
in  rachitis,  521 

secondary,  of  acute  anterior  pol- 
iomyelitis,  635 
in  neglected  talipes,  822 
of  spine.  antero-i:)osterior,  224 
Sprengel's,  230 

of  trunk,  in  acute  anterior  polio- 
myelitis,   633 
in    tuberculous    disease    of    the 

ankle-joint,  466 
of  upper  extremity,  498 


INDEX. 


889 


Deformity    of    upper    extremity    in 
acute    anterior   poliomye- 
litis, 633 
in  weak  foot,  709 
at  wrist,  congenital,  510 
Deviation,  lateral,   in   lateral  curva- 
ture of  the  spine,  151 
Diagnosis,   of    acute   anterior   polio- 
myelitis, 628 
of  Charcot's  disease,  297 
of  congenital  dislocation  of  the 

hip-joint,  545 
of  coxa  vara,  579 
differential,  between   congenital 
and  acquired  talipes,  849 
of  lumbar  Pott's  disease  in 
infancy,  50 
from  acute  rachitis,  50 
from  scurvy,  50 
of    tuberculous    disease    of 
the  spine,  46 
of    disease    of    the   spine,    land- 
marks in,  34 
of  hysterical  hip,  667 
of  lateral  curvature  of  the  spine, 
175 
mobility  in,  176 
posture  in,  175 
record   in,   176 
of    malignant     disease     of     the 

spine,  129 
of  sacro-iliac  disease,  146 
of  torticollis,  680 
of  tuberculous  disease  of  ankle- 
joint,   467 
of  bones  and  joints,  261 
of  hip- joint,  332 

x-ray  in,  836 
of  knee-joints,  426 
of  spine,  64 

Eoentgen  ray  in,  65 
of  typhoid  spine,  132 
of  weak  foot,  717 
Disabilities  of  foot,  694 
Dislocation  of  hip-joint,  congenital, 
536 
spontaneous,  411 
of  shoulder,  congenital,  498 
recurrent,  505 

treatment  of,  506 
Displacement  of  peronei  tendons,  779 

treatment  of,  780 
Distortions  of  the  fingers,  514 

of  limb  in  tuberculous  disease  of 

the  hip- joint,  314 
rachitic,  521 
Doigt  a  Eessort,  515 
Drop  finger,  515 
Dry  caries,  258 
Dupuytren's  contraction,  516 
etiology  of,  516 
pathology  of,  516 


Dupuytren's    contraction,    symx^toms 
of,  516 
treatment  of,  517 
Dysbasia  angiosclerotica,  767 
Dystrophy,  muscular,  661 


Effusion  at  knee,  quiet,  448 
Elbow,  deformities  of,  acquired,  508 
{see  Cubitus  valgus  and 
varus) 
congenital,  507 
Elbow- joint,  tuberculous   disease  of, 
485 
age  at  incipiency  of,  485 
occurrence   of,   485 
pathology  of,  485 
prognosis  in,  489 
symptoms  of,  486 
treatment  of,  487 

excision    of    elbow    in, 

488 
operative,  488 
Electrical  test  in  prognosis  of  acute 

anterior  poliomyelitis,  630 
Elongation    of   ligamentum   patellae, 
460 
etiology  of,  461 
symptoms  of,  461 
treatment  of,  461 
Enlargement  of  superficial  pretibial 

bursa,  453 
Epiphysitis   at   the   hip-joint,   acute, 
410 
symptoms  of,  410 
treatment  of,  410 
Erythromegalia,   766 
Excision   of   the   hip- joint   in  tuber- 
culous disease,  393 
Koenig's  method,  393 
Eydygier  's  method,  394 
statistics  of,  397 
in  treatment  of  triberculous  dis- 
ease   of    the    knee-joint, 
440 
results  of,  441 
Exercise  in  muscle-building,   207 
in  self-correction,  201 
in  treatment  of  knock-knee,  609 
609 
of  lateral  curvature  of  the 

spine,  184-200 
of  weak  foot,  730 
Exostoses  of  foot,  779 
Extra-articular  gluteal  bursitis,  413 
hip-joint  disease,  412 
iliopsoas  bursitis,  413 
treatment  of,  414 
tuberculous  disease  of  the  knee- 
joint,  437 
operative     intervention    in, 
437 


890 


INDEX. 


Femur,    bending    of    neck    of,    572 
(see  Coxa  vara) 
carcinoma  of,  414 
cysts  of,  414 
depression  of  neck  of,  572   (see 

Coxa  vara) 
fracture  of  neck  of,  585 
in  adult  life,  589 

open  operation 
in,  592 
epiphyseal,  fracture  of, 
587' 
treatment   of,   588 
simple,  585 

diagnosis  of,  586 
treatment  of,  587 
incurvation  of  neck  of,  572  (see 

Coxa  vara) 
partial   separation   of   epiphysis 
of  head  of,  in  adolescence,  588 
sarcoma  of,  414 
and  tibia,  changed  relations  of, 

in  knock-knee,  603 
traumatic  separation  of  epiphy- 
sis of  head  of,  585 
Finger,  baseball,  515 

contraction  of,  congenital,  514 

treatment  of,  514 
distortions  of,  514 
drop,  515 

Dupuytren  's  contraction  of,  516 
etiology,  516 
pathology,  516 
symptoms,   516 
treatment,   517 
jerking,  etiology  of,  515 

treatment  of,  515 
mallet,  515  (see  Drop-finger) 
snapping,     515      (see     Jerking 

finger) 
trigger,  515 
webbed,  514 

etiology  of,  514 
treatment  of,  514 
Flat-back,  224 
chest,  234 

treatment  of,  235 
Foetal  rachitis,  526  (see  Chondrodys- 

trophia) 
Foot,  in  activity,  697 
arches  of,  694 
club,    non-deforming,    748     (see 

Contracted  foot) 
considered  as  a  mechanism,  705 
constricting  bands  of,  845 
contracted,  748 

etiology  of,  748 
symptoms  of,  749 


Foot,  contracted,  treatment  of,  751 
operative,    752 
deficiency  of,  congenital,  844 
deformities  of,  785 
compound,  786 
congenital,   associated  with 
defective  development,  842 
disabilities   and   deformities  of, 

694 
exostoses  of,  779 
flat,  708  (see  Weak  foot) 
function  of  the  muscles  of,  704 
general    discription   of,   and   its 

functions,  694 
hollow,  748  (see  Contracted  foot) 
hypertrophy  of,  congenital,  844 
improper  postures  of,  699 
movements  of,  700 
oedema  of,  congenital,  846 
as  a  passive  support,  696 
splay,  708  (see  Weak  foot) 
tables    of    relative    strength    of 

muscles  of,  705 
weak,  708 

in  childhood,  724 

general   weakness,    726 
irregular  joints  of,  725 
outgrown  joints,  725 
symptoms  of,  724 
weak  ankles  in,  725 
deformities    of    legs    with, 

726 
diagnosis  of,  717 
attitude  in,  717 
bearing  surface  in,  719 
contour  in,  718 
distribution   of   weight 

and  strain  in,  718 
range  of  motion  in,  719 
etiology  of,  713 
extreme  types  of,  722 
limitation    of    motion    and 

muscular  spasm  in,  722 
pathology  of,  713 
review  of,   727 
rigid,  737 

functional  use  in  over- 
corrected       attitude. 
740 
treatment  of,  738 

adjuncts  in,  745 
forcible       overcor- 
rection in,   738 
operative,  746 
plaster     strapping 
in,  745 
varieties  of,  744 
symptoms  of,  715 
treatment  of,  728 

attitudes  in,   729 
brace  in,  734 
exercises  in,  730 


INDEX. 


891 


Foot,    weak,    treatment    of,    plaster 
cast,  732 
raising  inner  border  of 

shoe  in,  729 
shoe  in,  728 
support  in,  730 
varieties  of,  721 
Forcible  abduction   in   treatment   of 
coxa  vara,  589 
correction  by  reverse  leverage  in 
treatment  of  tuberculous  dis- 
ease of  knee-joint,  429 
Fracture  of  metatarsal  bones,  779 
of  neck  of  femur,  585 
in  adult  life,  589 
of  spine,  131 
Fragilitas  ossium,  529 
Friedrich's  disease,  663 
Function,   impairment   of,   in   Pott 's 

disease,  28 
Functional  affections   of  joints,   664 
pathogenesis  of  deformity,  240 

Wolff's  law   of,   240 
results  of  treatment  of  tubercu- 
lous disease  of  hip- joint,  444 
Funnel  chest,  236 

G 

Gait,  in  tuberculous  disease  of  spine 

in  lower  region,  39 
Genu  recurvatum,  acquired,  454 
etiology  of,  454 
symptoms   of,   454 
treatment   of,   455 
congenital,  455 

accompanying  deformi- 
ties   and    malforma- 
tions, 456 
etiology  of,  456 
treatment  of,  457 
valgum,  deformity  in,  outgrowth 
of,  597 
etiology  of,  595 
pathology  of,  607 
symptoms  of,  602 
time  of  onset  of,  595 
treatment  of,  608 
by  braces,  610 
expectant,  608 
manipulation  in,  608 
operative,  612 

osteoclasis,  614 
osteotomy,  613 
posture     and     exercise 
in,  609 
unilateral,   605 
varum,  595 

deformity  in,  outgrowth  of, 
597 
predisposition  to,  595 
time  of  onset,  595 
symptoms  of,  617 


Genu  varum,  treatment  of,  618 
by  braces,  618 
expectant,  618 
operative,  620 
Gluteal  bursitis,  413 
Gonorrheal  arthritis,  273 

distribution  of,  273 
of  hip-joint,  411 
in  infancy,  276 
purulent  form  of,  274 
serofibrinous  form  of,  274 
serous  form  of,  274 
symptoms  of,  274' 
treatment  of,  275 
rheumatism,  273  {see  Gonorrheal 
arthritis) 
of  spine,  133 
Gout,  292 

Growth,  retardation  of,  in  paralytic 
affections,  655 
in    tuberculous    disease    of 
hip-joint,  324 

H 

H.EMARTHROSIS,    296 

Hsem^atoma    of    sterno-mastoid    mus- 
cle, 675 
Hfemophilia,  295 

treatment  of,  295 
Hallux  flexus,  707 
rigidus,  767 

etiology  of,  768 
treatment  of,  768 
valgus,  772 

etiology  of,  773 
pathology  of,  773 
symptoms  of,  773 
treatment  of,  774 
operative,  774 
varus,  770 

treatment  of,   771 
Hammer-toe,  776 

symptoms  of,  777 
treatment  of,  777 
Harrison's  groove  in  rachitis,  521 
Heberden's    nodosities    in    osteo-ar- 

thritis,  287 
Heel,  painful,  765  {see  Calcaneobur- 

sitis) 
Hemorrhage  in  haemophilia,  295 

into  joints,  296  {see  Ha?marthro- 
sis) 
Hereditary  ataxia,  663 
High  hip  in  lateral  curvature  of  the 
spine,  156 
shoe  in  treatment  of  lateral  cur- 
vature of  the  spine,  222 
shoulder  in  lateral  curvature  of 
the  spine,  156 
Hip,  change  in  contour  of  in  tuber- 
culous disease  of  hip-joint,  319 


892 


INDEX. 


Hii3    disease,    304    {see    Tuberculous 
disease  of  the  Mp-joiut) 
hysterical,   667 
snapping,  571 

subluxation  of,  congenital,  571 
Hip-joint,  acute  epiphysitis  at,  410 
infectious  arthritis  of,  acute, 
410 
symptoms  of,  410 
treatment  of,  410 
subacute,  411 
disease,  extra-articular,  412 
dislocation  at,  congenital,  536 
anterior,  545 
bilateral,  544 
diagnosis  of,  545 
etiology  of,  541 
pathology  of,  537 
sujiracotyloid    displace- 
ment, 545 
symptoms  of,  542 

general,  544 
statistics  of,  536 
treatment  of,  547 

arthrotomy  in,  564 
in  infancy,  558 
Lorenz,  548-561 
older  subjects,  563 
open  operation,  565 
osteotomy   in,   565 
palliative,    571 
reduction,  551 
variations  in,  559 
unilateral,  542 
excision   of,  in   tuberculous  dis- 
ease, 393 
Koenig's  method,  393 
Eydygier's  method,  394 
gonorrheal  arthritis  of,  411 
malignant  disease  of,  414 
non-tuberculous     affections     of, 

409 
osteoarthritis  of,  414 
symptoms  of,  415 
treatment  of,  415 
spontaneous  dislocation  of,  411 
subacute  arthritis  of,  411 
traumatisms  at,  409 

treatment  of,  410 
tuberculous  disease  of,  304 
abscess  in,  387 

significance  of,  388 
statistics  of,  387 
treatment  of,  389 
actual    lengthening    of 
limb  in,  325 
shortening  of  limb 
in,  323 
in  adult,  386 
age    at    ineipiency    of, 

309 
amputation  in,  396 


Hip- joint,  tuberculous  disease  of,  bi- 
lateral, 384 
treatment  of,  385 
causes  of  death  in,  403 
combined   with   disease 

of  other  parts,  385 
correction  of  deformity 
by     femoral     osteot- 
omy, 399 
details    of    1000    cases 

of,  338 
diagnosis    of,    differen- 
tial, 332-336 
distortion    of    limb    in, 

314 
examination  in,  method 
of,  327 
measurements,  328 
physical,  328 
excision  of,  393 
in  infancy,  386 
Koenig's   statistics   of, 

317 
local  signs  of,  332 
measurements  in,  328 
method    of    estimating 
degree   of   distortion 
of  limb  in,  329 
mortality  in,  401 
natural  cure  in,  316 
physical  signs  of,  311 
prognosis  of,  401 

as  to  function,  404 
recording  case  of,  336 
reduction  of  deformity 
in  resistant  case  of, 
399 
sex  affected  in,  309 
side  affected,  309 
sinuses  in,  391 

treatment  of,  391 
symptoms  of,  309 
atrophy  as,  320 
change  in  contour 

of  hip  as,  319 
distortion   of  limb 

as,  314 
general,  327 
limp  as,  311 
night  cry,  310 
pain  as,  310 
stiffness  as,  311 
treatment  of,  339 
application    of 
plaster  spica 
bandage  in,  370 
during     stage     of 

recovery,  379 
immediate    reduc- 
tion  of   deform- 
ity in,  366 


INDEX. 


893 


Hip- joint,     tuberculous     disease     of, 
treatment        of, 
Lorenz         spica 
bandage  in,  374 
mechanical,  341 
by      plaster      sup- 
ports, 366 
practical  combina- 
tion of  traction, 
splinting        and 
stilting  in,  375 
reduction     of     de- 
formity,    imme- 
diate, 366 
removal    of    direct 
pressure  in,  368 
stilting  in,  341,  375 
Thomas'  brace  in, 

360 
traction  in,  341 
Hoffa's  treatment   for   paralysis   of 
deltoid   muscle   in    acute    anterior 
poliomyelitis,  645 
Hollow    foot,    748     (see    Contracted 

foot) 
Hyperaesthesia    of    skin    in    neurotic 

spine,  665 
Hyperplasia    of   fatty   tissue   within 

knee  joint,  451 
Hypertrophy  of  bone,  246 
Hysterical  club-foot,  667    (see  Hys- 
terical talipes) 
deformities,  664 
hip,  667 
joint  affections  and  deformities, 

664 
scoliosis,  666 
spine,  666 

symptoms  of,  666 


Idiopathic  osteopsathyrosis,  529  (see 

Fragilitas  ossium) 
Hiopsoas  bursitis,  413 
Incidental   lateral   curvature    of   the 
spine,  167 
synovitis  of  the  knee,  448 
Infancy,  acute  arthritis  in,  277 
etiology,  277 
prognosis,  278 
symptoms,   278    . 
treatment,  278 
gonorrheal  arthritis  in,  276 
lumbar  Pott 's  disease  in,  pecu- 
liarities of,  50 
tuberculous  hip  disease  in,  386 
Infantile   paralysis,   624    (see  Acute 
anterior  poliomyelitis) 
scorbutus,  528 

pathology  of,  528 
symptoms  of,  528 
treatment  of,  529 
Infectious  osteomyelitis,  280 


Intermittent  limp,  667 
Internal   derangement    of   the   knee- 
joint,  449 
displacement     of     a     semilunar 
cartilage,  449 
treatment  of,  450 
loose   bodies   in   the   kuee-joint, 
449 
Iodoform  filling  for  bone-cavities  in 
tuberculous    disease   of   bones 
and  joints,  263 
in  treatment  of  tuberculous  dis- 
ease of  bones  and  joints,  263 
Irregular  forms  of  torticollis,  692 


Jerking  finger,  515 

Joint  affections,  hysterical,  664   (see 

also  neurotic  joints,  668) 
Joints,   bones   and,   tuberculous    dis- 
ease of,  247 
double,  in   rachitis,   521 
functional  affections  of,  664 
hemorrhage  into,  295,  296 
inflammation  of,  gonorrheal,  273 
neurotic,  668 

etiology  of,  668 
symptoms  of,  669 
treatment  of,  670 
non-tuberculous  diseases  of,  269 
syphilitic  diseases  of,  269 
treatment  of,  273 
pain  and  swelling  of,  269 
tuberculous     disease     of,     other 
forms  of,  256 
Judson  's  brace  in  treatment  of  ac- 
quired  talipes   calcaneus, 
859 
of  infantile  club-foot,  806 

K 

Kingsley's  table  for  estimating  de- 
gree of  distortion  of  limb  in  tuber- 
culous disease  of  hip- joint,  332 
Knee,  back,  454   (see  Acquired  genu 
recurvatum) 
contraction  at,  congenital,  462 
general,  462 

prognosis  of,  462 
treatment  of,  462 
deformities  at,  congenital,  461 
displacement     of     a     semilunar 
cartilage  of,  449 
treatment  of,  450 
housemaid's,  452 

treatment  of,  452 
Knee-joint,  hyper2:)lasia  of  fatty  tis- 
sue within,  451 
treatment  of,  451 
injury  of,  in  childhood,  446 

muscular      cramp      of, 
446 


894 


INDEX. 


Knee-joint,     injury     of,     simulating 
displacement    of    semilu- 
nar cartilage  within,  450 
loose  bodies  in,  449 
malformations  of,   456 
non-tuberculous     affections     of, 
446 
deformities  of,  446 
other  deformities  of,  456 
quiet  effusion  at,  448 
snapping,  461 

treatment  of,  462 
strains  of,  in  childhood,  446 
synovitis  of,  acute,  446 

treatment  of,  446 
chronic,   447 
incidental,    448 
painless,  448 
recurrent,  447 
tuberculous  disease  of,  415 
abscess  in,  438 
actual    lengthening    of 
limb   in,  425 
shortening  in,  425 
deformity  in,  444 
diagnosis    of    from    ar- 
thritis        defor- 
mans, 427 
Charcot 's    disease, 

427 
hsemarthrosis,    427 
hysterical        joint, 

427 
infectious      arthri- 
tis,  427 
injury  of  knee,  427 
rheumatism,  427 
sarcoma,  427 
synovitis,  427 
distortion  in,  423 
etiology  of,  420 
extra-articular,  437 
mortality  in,  443 
pathology  of,  416 
prognosis  in,  443 
statistics  of  age  at  in- 
cipieney  of,  420 
functional    results 
of     conservative 
treatment,  444 
symptoms  of,  420 
synonyms  of  417 
synovial      tuberculosis, 

438 
treatment  of,  428 
accessory,  435 
amputation  in,  442 
arthrectoniyin,  439 
Billroth    splint   in, 

430 
during       convales- 
cence, 436 


Knee-joint,  tuberculous  disease  of, 
treatment  of,  ex- 
cision in,  440 
forcible  correction 
by  reverse  lever- 
age in,  429 
functional    results 

of,  444 
mechanical,  432 
operations   for   re- 
lief of  final  de- 
formity in,  442 
plaster,      bandage 

in,  429 
reduction     of     de- 
formity in,  428 
traction   in,   429 
Knock-knee,  601 

attitude  in,  accommodative,  603 

of  rest  in,  597 
changed  relation   of  femur  and 

tibia  in,  603 
combined  with  bow  legs,  605 
and  general  rachitic  distor- 
tions,  605 
deformity  in,  measurements  of, 
607 
outgrowth  of,  597 
predisposition  to,  595 
secondary,  604 
etiology  of,  595 
gait  in,  605 
pathology  of,  607 
time  of  onset  of,  595 
treatment  of,   608 
by  Graces,  610 
exercise  in,  609 
expectant,    608 
manipulation  in,  608 
operative,  612 

osteoclasis  in,  614 
osteotomy   in,    613 
plaster  bandage  in,  612 
posture  in,  609 
unilateral,   605 
Koenig's  statistics  of  abscess  in  tu- 
berculous disease  of  knee- 
joint,  438 
of     non-tuberculous     affec- 
tions of  hip-joint,  409 
of    tuberculous    disease    of 
hip-joint,  317 
Kyphosis,  224 

of  adolescents,  140,  224 
postural,  225 
in  rachitis,  521 
symptoms,  227 
treatment  of,  227 


Late  rickets,  525 

Lateral  curvature  of  spine,  149   (see 
Spine,  lateral  curvature  of) 


INDEX. 


895 


Leg,  muscular  cramp  of,  446 
Leverage,  reverse,  forcible  correction 
by,    in    treatment    of    tuberculous 
disease  of  knee-joint,  429 
Ligaments,  spinal,  rupture  of,  131 
Ligamentum  patellae,   elongation  of, 
460 
etiology  of,  461 
symptoms  of,  461 
treatment  of,  461 
Limb,  actual  lengthening  of,  in   tu- 
berculous  disease   of 
hip-joint,  325 
of  knee-joint,  425 
shortening     in     tuberculous 
disease  of  knee-joint,  425 
apparent  lengthening  of,  in  tu- 
berculous disease  of  hip- 
joint,  314 
shortening    of,    in    tubercu- 
lous disease  of  hip- joint, 
315 
distortion   of   limb,   in   tubercu- 
lous  disease   of   hip- 
joint,  314 
of  knee-joint,  423 
methods    of    estimation    of 
degree  of,  in  tuberculous 
disease   of  hip- joint,   329 
Limp,  intermittent,  667 

as  symptom  of  tuberculous 
disease  of  hip-joint,  311 
Linear    osteotomy    in    treatment    of 

coxa  vara,  583 
Lipoma       arboreseens,      tuberculous 

joint  disease  in,  257 
Localized  osteom.yelitis,  282 
liOose  bodies  in  knee-joint,  449 
Lordosis,  229 

treatment  of,  230 
in  tuberculous  disease  of  spine 
in  lower  region,  39 
Lorenz    operation    in    treatment    of 
congenital  dislocation  at  hip-joint, 
548 
Lovett  's  table  for  estimating  degree 
of  distortion  of  limb  in  tubercu- 
lous disease  of  hip-joint,  330 

M 

Malleotomy,  in  treatment   of   neg- 
lected talipes,  823 
Mallet-finger,  515 

Manipulation    in    treatment    of    ac- 
quired    talipes     equinus, 
853 
of  torticollis,  682 
Manual  correction,  forcible,  in  treat- 
ment of  neglected  talipes, 
815 
in    treatment    of    infantile 
club-foot,  812 


Measurements  in  tuberculous  disease 

of  hip-joint,  328 
Melos-extremity,  135 
Metatarsal  arch,  anterior,  755 
weakness  of,  753 
bones,   fractures   of,   779 
Metatarsalgia,  anterior,  753 
etiology  of,  754 
influence  of  shoe  in  causing 
disability    and   pain,    757 
pathology,  759 
treatment  of,  759 
operative,  760 
Metatarsus  varus,  772 
Mollitis     ossium,     530     (see     Osteo- 
malacia ) 
Morbus  coxfe,  304    (see  Tuberculous 

disease  of  hip-joint) 
Morton's    neuralgia,    753     (see    An- 
terior metatarsalgia) 
Muscles,   pectoral,    defective   forma- 
tion of,  234 
Muscular  atrophy,  progressive,  661 
deformity  in  Pott 's  disease,  28 
dystrojahy,  661 

paralysis,       laseudohypertropMc, 
662 
diagnosis  of,  663 
treatment  of,  663 
Myelopathic  atrophy,  661 
paralysis,  661 

N 
Nerve     grafting    in     treatment     of 

acute  anterior  poliomyelitis,  648 
Nervous  system,  diseases  of,  624 
Neuralgia,  Morton's,  753  (see  Meta- 
tarsalgia, anterior) 
plantar,  766 

treatment  of,  766 
Neuritis,  664 
Neurotic   joints,   668 

etiology  of,  668 
symptoms  of,  669 
treatment  of,  670 
spine,  664 

symptoms  of,  665 
treatment  of,  666 
' '  Night-cry  ' '  in  Pott 's  disease,  28 
as  symptom  of  tuberculous  dis- 
ease of  hip-joint,  310 
Non-deforming    club-foot,    748    (see 

Contracted  foot) 
Non-tuberculous   affections   of  knee- 
joint,  446 
of  spine,  128 
deformities  of  knee-joint,  446 
diseases  of  joints,  269 


Obstetrical      injury      to      brachial 
plexus,  repair  of,  503 


896 


INDEX. 


Occupation,  causing  lateral  curvature 
of  spine,  167 
inducing    deformity    in    lateral 
curvature  of  spine,  170 
Ocular  torticollis,  692 
OEdema  of  the  feet,  congenital,  8^6 
Opisthotonos,  cervical,  692 
Osteitis  deformans,  142,  531 
Osteo-arthritis,  282 
etiology  of,  285 
Heberden's  nodosities  in,  287 
of  hip-joint,  414 

symptoms  of,  415 
treatment  of,  415 
pathology  of,  283 
symptoms   of,   286 
treatment  of,  287 
Osteoarthropathy,  hypertrojihic,   sec- 
ondary, 533 
Osteoclondritis,  syphilitic,  269 
Osteoclasis    in   treatment    of   knock- 
knee,  614 
Osteoclasts  in  treatment  of  neglected 

talipes,  829 
Osteomalacia,  530 

in  childhood,  530 
local,  531 
treatment  of,  531 
Osteomyelitis,  acute,  280 
infectious,  280 
localized,   282 
of  spine,  acute,  129 

symptoms,   129 
treatment,  130 
Osteoperiostitis,  syphilitic,  269 
Osteopsathyrosis,   idiopathic,  529 
Osteotomy   in  congenital   dislocation 
at  hip-joint,  565 
cuneiform,  in  treatment  of  coxa 
vara,  583 
of  knock-knee,  614 
of  neglected  talipes,  834 
linear,    in    treatment    of    coxa 

vara,  583 
secondary,      in       treatment      of 

neglected  talipes,  833 
in   treatment   of   acute   anterior 
poliomyelitis,  648 
of  knock-knee,  613 
Overcorrection,     forcible,     in     treat- 
ment of  rigid  weak  foot,  738 
Overlapping  toes,  778 


Paget 's  disease   (see  Osteitis  defor- 
mans, 142) 
Painful  great  toe,  767 

treatment  of,  768 
toe- joint  in   older  subjects, 
769 
heel,  765 

treatment  of,  765 


Painless  synovitis  of  knee^  448 
Paralysis    in    acute    anterior    polio- 
myelitis, of  arm, 
642 
of     anterior     mus- 
cles of  leg,  637 
distribution  of,  626 
effects  of,  631 
of   muscles   of   the 

hip,  640 
of    posterior    mus- 
cles  of   the   leg, 
637 
of    thigh    muscles, 
638 
of  arm,  obstetrical,  498 

treatment  of,  499 
cerebral,  of  childhood,  650 
acquired,  651-654 
congenital,  653 
distribution  of,  651 
diphtheritic,  692 
infantile,  624   (see  Acute  anter- 
ior poliomyelitis) 
local,    comj^licatiug    Pott  'a    dis- 
ease, 125 
muscular,       pseudohypertrophic, 
662 
diagnosis  of,  663 
treatment  of,  663 
myelopathic,  661 
myopathic,  661 
in  Pott's  disease,  29 
spastic  spinal,  660 
Paralytic  torticollis,  692 
Paraplegia.  Pott's,  117 

duration   of,   119 
liability  to,  in  different  re- 
gions of  spine,  118 
prognosis  in,  121 
symptoms,  119 
time  of  onset  of,  119 
treatment  of,  122 
operative,  123 
Patella,  absent,  457 

treatment  of,  457 
displacement  of,  acquired,  457 

congenital,  457 
rudimentary,  457 
slipping,  458 

etiology  of,  458 
symptoms  of,  459 
treatment  of.  459 
operative,  459 
Pectua  carinatum,  235 

excavatum,  236 
Pelvis,  inclination  of,  35 
Periarthritis,  scapulohumeral,  493 
symptoms  of,  493 
treatment  of,  495 
operative,  49o 
Peronei  tendons,  displacement  of,  779 


INDEX. 


897 


Peronei    tendons,    displacement     of, 

treatment  of,  780 
Persistent    abduction   in   weak   foot, 

722 
Pes  planus,  723 

Phalanges,    displacements    of,     con- 
genital, 514 
Phelp  's   operation,   in   treatment    of 

neglected  talipes,  830 
Pigeon  breast  in  rachitis,   521 
chest,  235 

in    tuberculous    disease    of 
spine  in  thoracic  region, 
53 
toe,  771 
Plantalgia,  766 
Plantar  neuralgia,  766 

treatment   of,   766 
Plaster  bandage  in  treatment  of  in- 
fantile club-foot,  802 
of  knock-knee,  612 
of    tuberculous   disease 
of   knee-joint,   429 
cast,    in    making    of    brace    for 

weak  foot,  732 
corset,  92 

jacket,  in  treatment  of  tubercu- 
lous disease  of  sjjine, 
75 
application    of,    in    re- 
cumbent posture,  87 
Calot,  83 
strapping  in  treatment  of  rigid 
foot,  745 
Poliomyelitis,  anterior,  acute,  624 
age  at  onset  of,  625 
deformity  in,  causes  of, 
631 
functional    use    as 

cause  of,  633 
gravity    and    mus- 
cular   action    as 
cause  of,  631 
habitual      posture, 
632 
deformities,  of  neck  in, 
633 
reduction  of,  643 
secondary,  635 
subluxation,  633 
of  trunk  in,  633 
of  upper  extremity 
in,  633 
diagnosis  of,  628 

from     diphtheritic 

paralysis,  629 
from,  joint  disease, 

628' 
from  multiple  neu- 
ritis, 629 
from       obstetrical 
paralysis,  629 

57  y 


Poliomyelitis,  anterior,  acute,  diag- 
nosis of,  from 
other  forms  of 
spinal  paralysis, 
628 
from  paralysis  of 
cerebral  origin 
in  childhood,  628 
from   Pott 's  pa.ra- 

plegia,  628 
from   pseudoparal- 
ysis, 629 
from    rheumatism, 

628 
from  spastic  spinal 
paraplegia,  628 
etiology  of,  625 
paralysis    of    different 
muscles  in,  effects  of, 
upon  function,  631 
pathology  of,  624 
prognosis  in,  630 
retardation    of    groAvth 

in,  635 
symptoms  of,  626 
treatment  of,  636 
mechanical,  637 
operative,  643 
of   paralytic   scoli- 
osis, 642 
Popliteal  region,  bursse  and  cysts  in, 

453 
Postural  kyphosis,  225 
Posture  in  treatment  of  knock-knee, 

609 
Potbelly,  in  rachitis,  521 
Pott's  disease,  17    (see  Tuberculous 
disease  of  the  spine) 
lumbar,    in    infancy,    pecu- 
liarities of,  50 
paraplegia,  117 
Prepatellar  bursitis,  452 

treatment   of,  452 
Pretibial  bursa,  superficial,  enlarge- 
ment of,  453 
bursitis,  452 

symptoms  of,  452 
treatment  of,  453 
Progressive  muscular  atrophy,  661 

myelopathic    form    of, 

661 
myopathic  form  of,  661 
Pseudohypertrophic   muscular   jjaral- 

ysis,  662 
Pseudoparalysis,  in  rachitis,  523    , 
Psoas  contraction  in  tuberculous  dis- 
ease of  spine  in  lower  region,  40 
Psychical  torticollis,  693 
Puerperal  arthritis,  276 

Q 

Quiet  effusion  at  knee,  448 


898 


INDEX. 


R 

Kecurrent   dislocation   of   shoulder, 
505 
treatment  of,  506 
operative,  507 
synovitis  of  knee,  447 
Eetardation  of  growth  in  acute  an- 
terior poliomyelitis,  635 
Eetention  brace  in  treatment  of  in- 
fantile club-foot,  810 
Eetrocalcaneobursitis,  761  (see  Aehil- 

lobursitis) 
Eachitic  attitude,  142,  523 

distortions   of  lower   limb,   gen- 
eral, 623 
rosary,  521 
spine,  140 

natural  cure  of,  142 
treatment  of,  141 
torticollis,  692 
Eachitis,  519 

age  at  onset  of,  519 
attitude  in,  523 
caput  quadratum  in,  521 
craniotabes  in,  521 
cubitus  valgus  in,  522 

varus  in,  522 
deformities  in,  521 

prevention  of,  525 
double  joints  in,  521 
etiology  of,  519 
foetal,   526    (see   Chondrodystro- 

phia) 
Harrison's  groove  in,  521 
kyjihosis  in,  521 
pathology  of,  520 
pigeon  breast  in,  521 
pot-belly  in,  521 
prognosis  in,  523 
pseudoparalysis  in,  523 
rosary  in,  521 
scoliosis  in,  521 
symptoms  of,  521 
treatment  of,  524 
Eheumatism,  293 

gonorrheal,  273   (see  Gonorrheal 

arthritis) 
of   spine,    133    (see    Spondylitis 
deformans) 
Eheumatoid  arthritis,  282 
in  childhood,  290 
etiology  of,  285 
symptoms  of,   286 
treatment   of,   287 
Eibs,  absence  of,  234 

cervical,  232 
Eice-bodies,  in  tuberculous  joint  dis- 
ease, 257 
Rickets,  519   (see  Eachitis) 
late,  525 


Eickets,  scurvy,  528   (see  Scorbutus, 

infantile) 
Eigid  weak  foot,  737 

treatment  of,  738 
Eotary    lateral    curvature    of    spine, 

149 
Eotation    in     lateral     curvature     of 

spine,  151 
Eound  back,  223 

hollow,  224 
shoulders,  225 
Eudimentary  patella,  457 
treatment  of,  457 

S 

Sacro-iliac   articulation,   injury   of, 
148 
disease,  146 

diagnosis  of,  146 
prognosis  in,  146 
symptoms  of,  146 
treatment  of,  147 
Sarcoma  of  femur,  414 

of  spine,  128 
Scapula,  congenital  elevation  of  (see 

Sprengel's  deformity,  230) 
Scapular  crepitus,  236 
Scapulohumeral     periarthritis,      493 
(see  Periarthritis  of  the  shoulder) 
Sciatic  scoliosis,  145 
Sciatica,  deformity  secondary  to,  145 
Scoliosis,  149   (see  Lateral  curvature 
of  the  si:)ine) 
hysterical,  666 
in  rachitis,  521 
Scorbutus,  296 

infantile,  528 

pathology  of,  528 
symp)toms  of,  528 
treatment  of,  529 
Scurvy,   296 

rickets,  528 
Secondary   deformities   in    neglected 
talipes,  822 
in      hypertrophic      osteoarthro- 
pathy, 534 
Septic  infection   in   tuberculous   dis- 
ease of  bones  and  joints,  258 
Shaffer  extension  shoe  in  treatment 

of  acquired  talipes  equinus,  853 
Shoes,  780 

in  treatment  of  weak  foot,  728 
Shoulder,   dislocation  of,  congenital, 
498 
reduction  of  deformity 
in,  500 
recurrent,  505 

treatment  of,  506 
ojierative,  507 
Shoulder-joint,   bursitis   at,   chronic, 
496 


INDEX. 


899 


Shoulder- joint,  periarthritis  of,  493 

symptoms  of,  493 

treatment  of,  495 

operative,  495 

tuberculous  disease  of,  481 

age    at    ineipiency    of, 

482 
pathology  of,  482 
prognosis  in,  484 
symptoms  of,  482 
treatment  of,  484 
operative,  484 
Sinuses  in  tuberculous  disease  of  the 

hip,  treatment  of,  391 
Skin,   hypergesthesia   of,   in   neurotic 

spine,    665 
Slipping  patella,  458 

etiology  of,  458 
symptoms  of,  459 
treatment  of,  459 
operative,  459 
Snapping  finger,  515 
hip,  571 
knee,  461 

treatment  of,  462 
Socks,  784 

Spasmodic  torticollis,  687 
etiology   of,    687 
pathology  of,  687 
prognosis  in,  688 
treatment  of,  688 
Spastic  paralysis,  651   {see  Cerebral 
paralysis  of  childhood) 
spinal  paralysis,  660  * 

Spina  bifida  and  talipes,  846 

ventosa,  491 
Spinal  cord,  length  of,  35 

ligaments,  rupture  of,  131 
paralysis,  spastic,  660 
Spine,  actinomycosis  of,  130 

antero-jjosterior   deformities   of, 
224 
kyphosis,   224 

symptoms  of,  227 
treatment  of,  227 
lordosis,  229 

treatment  of,  230 
arthritis  of,  infectious,  132 
gonorrheal,  133 
sub-occipital  region,  133 

treatment,  133 
typhoid,  132 

diagnosis,  132 
treatment,  132 
carcinoma  of,  128 
changes  in  contour  of,  in  Pott's 

disease,  28 
deformity  of,  tabetic,  142 
divisions  of,  32 
fracture  of,  130 
gonorrheal  rheumatism  of,  133 
hysterical,  666 


Spine,  hysterical,  symptoms  of,   666 
treatment  of,  668 
injury  of,  130 

landmarks,  in  diagnosis  of  dis- 
ease of,  34 
lateral  curvature  of,  149 

changes   in   antero-pos- 
terior  contour  in,  155 
compensatory     deform- 
ity in,  165 
congenital,  168 
deviation  in,  151 
diagnosis  of,  175 
due  to  occupation,  167 
etiology  of,  161 
hereditary  influence  in, 

'170 
high  hip  in,  156 

shoulder  in,  156 
incidental,   167 
occupation  as  inducing 

deformity,  167,  170 
pathology  of,  157 
predisposing  causes,  164 
prevention    of    deform- 
ity in,  181 
prognosis,  177 
records   of,    176 
relative    frequency    of, 

161 
rachitic,   169 
rotation  in,  151 
secondary  to  deformity 
elsewhere,  165 
to    disease    within 
thoracic      walls, 
166 
to  paralysis,  165 
symptoms  of,  174 
summary  of,  179 
treatment  of,  180 

braces   in,   use   of, 

219 
corrective,        com- 
bined with   sup- 
port,  215 
duration  of,  222 
exercises  in,  184 
forcible   correction 
of    deform- 
ity in,  218 
combined  with 
fixation,  215 
general,  222 
high  shoe  in,  222 
principles  of,  181 
posture  in,  184 
removal   of   super- 
incumbent weight 
in,  220 


900 


IXDEX. 


Spine,  lateral  curvature  of  treatment 
of,    removal    of, 
by      self-suspen- 
sion, 220 
supplemental,    220 
Yolkmann  seat  in, 
222 
varieties   of    deformity 
in,  172 
ligaments  of,  rupture  of,  131 
malignant  disease  of,  128 

diagnosis  of,  129 
neurotic,  66i 

hvperfesthesia     of    skin    in, 

■  665 
symptoms  of,  665 
treatment  of,  666 
non-tuberculous     affections     of, 

128 
normal,    contour   and   flexibility 

of,  30 
osteoarthritis  of.  133  (see  Spjon- 

dylitis  deformans) 
osteomyelitis  of,  acute,  129 
symptoms  of,  129 
treatment  of,  130 
rachitic,  140 

diagnosis    of.    from    Pott's 

disease,  50 
natural  cure  of,  142 
treatment  of,  141 
rheumatism  of,  133  (see  Spondy- 
litis deformans) 
rheumatoid  arthritis  of.  137 
sarcoma  of,  128 
syphilis  of.  128 
tabetic  deformity  of,  142 
typhoid,  132 

tuberculous  disease  of,  17 
abscess.  109 

treatment  of,  113 
correction  of  deformity 

in,  123 
diagnosis  of,  60,  65 
Eoentgeu   rays  in, 
65 
history  in,  36 
later  effects  of  deform- 
ity in.  126 
in  lower  region.  38 

diagnosis     of, 
differential, 
46 
gait  in.  39 
location    of 

pain  in,  40 
lordosis  in,  40 
pelvic    abscess 

in,  45 
psoas  contrac- 
tion in,  40 


Spine,    tuberculous     disease    of,    in 
lovrer        re- 
gion, paral- 
ysis in.  117 
time  of  onset, 

119 
treatment    of, 

122 
phvsical   signs 
of,  37 
rational  signs  of.  35 
recurrence  of.  126 
secondarv     deformities 

of,  126 
thoracic  region,  abscess 
in.  55 
aimless   cough 

in.    54 

attitudes  in,  52 

deviation      of 

spine  in,  54 

diagnosis     of, 

55 
gait  in.  -54 
muscular 

spasm  in,  54 
pain   in,    53 
pigeon      chest 

in,   53 
respiration  in, 

53 
treatment    of, 
66 
in  upper  region,  57 
abscess  in,  59 
attitude  in,  58 
symptoms  of,  58 
typhoid.  132 

diagnosis  of.  132 
treatment  of.  132 
variations  in  contour  of,  223 
Splint,  Billroth,  in  treatment  of  tu- 
berculous disease  of  the  knee- 
joint,  430 
'  in  treatment   of   infantile  club- 
foot, 806 
Spondylitis  deformans,  133 
pathology  of.  134 
symptoms  of,  136 
synonyms  of.  133 
treatment  of,  139 
varieties  of.  134 
superficialis,  18 
traumatic,  131 

treatment  of.  132 
Spondylolisthesis.  142 

treatment.  143 
Spondylose    rhizonielique,    135     (see 
spondylitis  deformans) 


INDEX. 


901 


Spontaneous  dislocation  of  the  hip- 
joint,  411 
subluxation  of  tlie  wrist,  509 
etiology  of,  510 
treatment  of,  510 
Sprain  of  ankle,  473 
chronic,  476 

treatment  of,  476 
etiology  of,  473 
symptoms  of,  473 
treatment  of,  473 

strapping  in,  474 
of  the  wrist,  496 
chronic,  496 
Sprengel's  deformity,  230 
etiology  of,  232 
treatment  of,  232 
Sternomastoid  muscle,  heematoma  of, 
675 
treatment  of,  683 
Stiffness,    as    symptom    of    tubercu- 
lous disease  of  the  hip-joint,  311 
Still's  polyarthritis,  289,  290 
Strains  of  knee  in  childhood,  446 

of  the  tendo  Achillis,  764 
Strapping  in  treatment  of  sprain  of 

the  ankles,  474 
Subacute  arthritis  of  hip-joint,  411 
Subastragaloid  disease,  467 
Subluxation  of  the  clavicle,  237 
treatment  of,  237 
of  hip,  congenital,  571 
of  wrist,  509 

etiology  of,  510 
spontaneous,  509 
treatment  of,  510 
Supracotyloid  dislocation  of  the  hip- 
joint,  545 
Swelling  about  ankles,  480 
Synovial     tuberculosis,     arborescent, 
256 
of  knee-joint,  438 

treatment  of,  438 
Synovitis  of  the  knee,  acute,  446 
treatment  of,  446 
chronic,  447 
incidental,  448 
painless,  448 
recurrent,  447 
Syphilis  of  spine,  128 
diagnosis  of,  128 
Syphilitic  diseases  of  joints,  269 
osteochondritis,  26'9 
osteoperiostitis,  270 
pain  and  swelling  of  joints,  270 
treatment,  273 


Tabetic  arthropathy,  296  {see  Char- 
cot's disease) 
deformity  of  the  spine,  142 
Talipes,  785 


Talipes,  acquired,  667,  788,  847 

deformity    in,    development 

of,  848 
diagnosis,    differential,    be- 
tween congenital  and  ac- 
quired, 849 
etiology  of,  847 
arcuatus,  748  {see  Hollow  or  con- 
tracted foot) 
calcaneovalgus,  787 
acquired,  866 

treatment  of,  867 
congenital,  842 
calcaneovarus,  787 
acquired,  866 

treatment  of,  867 
congenital,  842    ■ 
calcaneus,  786 

acquired,  857 

deformity   in,    develop- 
ment of,  858 
etiology  of,  858 
symptoms  of,  858 
treatment  of,  858 

Judson's  brace  in, 

859 
operative,  860- 
congenital,  840 
cavus,  748  {see  Contracted  foot) 
congenital,  667,  788 
anatomy  of,  795 
etiology  of,  789 
other  varieties  of,  839 
statistics  of,  793 
equinocavus,  congenital,  842 
equinovalgus,  787 

associated    with    congenital 
absence  of  fibula,  842 
etiology  of,  843 
statistics  of,  843 
treatment  of,  844 
congenital,  841 
equinovarus,  787 

anatomy  of,  795 
associated    with    congenital 
absence  of  the  tibia, 
844 
prognosis  of,  844 
statistics  of,  844 
infantile,  treatment  of,  800 
symptoms  of,  799 
treatment   of,   800 
equinus,  786 

acquired,  849 

etiology  of,  850 
symptoms  of,  851 
treatment   of,   852 

arthrodesis  in,  856 
immediate     correc- 
tion  of   deform- 
ity in,  853 


902 


INDEX. 


Talipes  equinus,  acquired,  treatment 
of,        manipula- 
tion in,  853 
Shaffer     extension 
shoe  in,  853 
congenital,  840 
infantile,  treatment  of,  800 
first  stage  of,  801 
Juclson  's  brace  in,  806 
manual    correction    in, 

812 
mechanical,   802 
plaster  bandage  in,   802 
preliminary    manipula- 
tion in, "802 
rectification       of       de- 
formity in,  801 
retention  brace  in,  810 
second  stage  of,  809 
splints   and   braces   in, 

806 
supervision  in,  813 
support  in  second  stage 

of,  809 
Taylor's  brace  in,  810, 

811 
tenotomy  in,  808 
neglected,  secondary  deformities 
in,  822 
treatment  of,  813 

age  as  influencing,  814 
division  of  tendo  Achil- 

lis  in,  825 
forcible  manual  correc- 
tion in,  815 
importance      of      func- 
tional use  in,  820 
malleotomy  in,   823 
method  of  Julius  Wolif 

in,  826 
open    incision     method 

of,  825 
operations  in,  833 
by  osteoclast,  829 
Phelps'     operation    in, 

830 
rapid  correction  of  de- 
formity in,  814 
simple  mechanical  rec- 
tification of  deform- 
ity  in   walking   chil- 
dren    and     in     later 
years,  835 
subcutaneous  tenotomy 

in,  823 
Thomas '      method     in, 

829 
by  wrenches,  828 
paralytic,  arthrodesis  in,  879 
tendon  splicing  in,  879 

transplantation,        870, 
871 


Talipes  plantaris,  748  (see  Hollow  or 
contracted  foot) 
spina  bifida  and,  846 
statistics  of,  793 
valgocavus,  congenital,  842 
valgus,  786 

congenital,  841 
varieties  of,  786 
varus,  786 

associated    with    congenital 
absence  of  the  tibia,  844 
congenital,  839 
Tarsus,  tuberculous  disease  of,  472 

treatment  of,  473 
Taylor's  brace   in   treatment   of  in- 
fantile club-foot,  811 
Tendo  Aehillis,  division  of  in  treat- 
ment of  neglected  talipes, 
825 
strain  of,  764 
Tendon  transplantation  in  treatment 
of  paralytic  deform- 
ities, 645 
of     paralvtie      talipes, 
870 
Tenosynovitis  at  ankle-joint,  478 

at   wrist -joint,    497 
Tenotomy,  in  treatment  of  infantile 
club-foot,  808 
of  neglected  talipes,  823 
of  torticollis,  683 
Thomas  brace,  in  treatment  of  knock- 
knee,  610 
knee  brace  in  treatment  of  tu- 
berculous disease  of  the  knee- 
joint,  436 
method    in    treatment    of    neg- 
lected talipes,  829 
treatment    of    rigid   weak   foot, 

745 
wrench  in  treatment  of  acquired 
talipes  equinus,  853 
Tibia,  absence  of,  congenital,  associ- 
ated   with    talipes    varus    or 
equinovarus,  844 
anterior  curvature  of,  621 
symptoms  of,  621 
treatment  of,  622 
displacement  of,  455   (see  Genu 
recurvatum  congenital) 
Tibial  tubercle,  injury  of,  453 
treatment  of,  453 
Toe,  hammer,   776 

symptoms  of,  777 
treatment  of,  777 
-joint,  painful,  great,  769 
overlapping,  778 
painful,  great,  767   (see  Hallux 
rigidus) 
etiology  of,  768 
treatment  of,  768 


INDEX. 


903 


Toe,  pigeon,   771 
Torticollis,  671 

acquired,  671,  676 
acute,  677 

etiology  of,  677 
spastic,   678 
symptoms  of,  679 
treatment  of,  686 
chronic,  682 

treatment  of,  682 
congenital,  672 

etiology  of,  674 
pathology  of,  676 
treatment  of,  682 

by  manipulation,  682 
by  open  method,  684 
overcorrection     of     de- 
formity in,   684 
subcutaneous   tenotomy 
in,  683 
diagnosis  of,  680 

from  arthritis,  681 
from  Pott's  disease,  680 
following  diphtheritic  paralysis, 

677,  692 
irregular  forms  of,  692 
hsematoma  in,  683 

as  a  possible  cause  of,  675 
ocular,  692 

operation  by  oj^en  method,  684 
for  spasmodic  form  by  sec- 
tion   of    spinal    accessory 
nerve,  688 
by   subcutaneous   tenotomy, 
683 
paralytic,  692 
psj-chical,  693 
rachitic,  692 
spasmodic,  687 

etiology  of,  687 
pathology  of,  687 
prognosis  in,  688 
treatment  of,  688 
■treatment  of,  682 
Traction    in   tuberculous   disease    of 
hip- joint,  341 
of  knee-joint,  429 
Transplantation  of  sartorius  muscle, 
647 
tendon,  in  acute  anterior  polio- 
myelitis, 645 
of  paraplegia,  659 
of  paralytic  talipes,  870 
Traumatic  coxa  vara,  585 

epiphyseal  fracture,  587 
spondylitis,  131 

treatment  of,  132 
Traumatisms  at  hip-joint,  409 

treatment  of,  410 
Treatment  of  abscess  in  tuberculous 
disease     of     the 
hip,  389 


Treatment  of  abscess  in  tuberculous 
disease  of  knee-joint,  438 
accessory,  of  tuberculous  disease 

of  knee-joint,  435 
of  Achillo-bursitis.  763 

operative,  764 
acquired  genu  recurvatum,  457 
talipes   calcaneovalgus,   867 
calcaneovarus,  867 
calcaneus,  858 
equinovalgus,    869 
equinovarus,  868 
equinus,  852 
torticollis,  682 
acute  anterior  poliomyelitis,  636 
epiphj'sitis  at  hip-joint,  410 
infectious   arthritis   of   hip- 
joint,  410 
osteomyelitis  of  spine,  130 
torticollis,  686 
anchylosis,  299 
anterior  bow-leg,  623 

metatarsalgia,  759 
arthritis  complicating  infectious 
diseases,  276 
deformans,  287 
hypertrophic,  287 
of    suboccipital    region    of 
the  spine,  133 
Bier 's,  of  tuberculous  disease  of 
bones  and  joints,  264 
of  the  knee-joint,  436 
bilateral  hip-disease,  385 
bow-leg,  618 
bursitis,  414 
calcaneobursitis,   765 
cerebral  paralysis  of  childhood, 

656 
Charcot 's  disease,  298 
chondrodystrophia,  528 
chronic  sprain  of  ankle,  476 
club-liaud,  513 

congenital  contraction  of  fingers, 
514 
contraction  of  knee,  462 
dislocation  at  hip-joint,  547 
elevation    of    the    scapula, 

232 
genu  recurvatum,  457 
torticollis,  682 
contracted  foot,  751 
coxa  vara,  581 

displacement     of     perouei     ten- 
dons, 780 
Dupuytren  's  contraction,  517 
during  convalescence  from  tuber- 
culous   disease    of    knee-joint, 
436 
elongation  of  ligamentum  patel- 
la?, 461 
extra-articular   disease   of  knee- 
joint,  437 


904 


IXDEX. 


Treatment,  flat  chest,  235 

gonorrheal   arthritis,  275 
hallux  rigidus,  768 
valgus,  774 

operative,  774 
varus,  771 
hsemophilia,  295 
hammer-toe.   777 
hemiplegia  in  cerebral  paralysis 

of  childhood,  656 
hysterical  hip,  667 

joint  aiJections,  664 
sjiine.   668 
infantile  talipes,  800 
internal    derangement    of   knee- 
joint.  450 
jerking  finger,  515 
knock-knee,  608 
kyphosis,  227 

lateral  curvature  of  spine,  181 
lordosis.  230 
neurotic  joints.  668 

spine,  666 
obstetrical  paralysis  of  arm,  499 
osteoarthritis.  287 

of  hip-joint.  415 
osteomalacia,  531 
pain  in  lower  portion  of  back, 

144 
painful  heel,  765 
paralysis,  in  tuberculous  disease 

of  spine,  122 
paralytic  scoliosis.  642 
paraplegia,  in  cerebral  piaralysis 
of  childhood,  659 
Pott's,  122 
periarthritis  of  shoulder,  495 
pigeon  chest.  236 
plantar  neuralgia.  766 
prepatellar  bursitis,  452 
pretibial  bursitis.  453 
recurrent    dislocation    of    shoul- 
der. 506 
rachitic  spine.  141 
rachitis.  524 

rheumatoiil  arthritis.  287 
rudimentary  patella.  457 
saero-iliac  disease,  147 
scorbutus.  529 
sinuses,    in    tuberculous    disease 

of  hip-joint.  391 
slipping  patella,  459 
snapping  finger,  515 

knee,  462 
spasmodic  torticollis,  688 
spondylitis  deformans,  139 
sprain  of  ankle.  473 

chronic.   476 
Sprengel  's  deformity,  232 
subluxation  of  clavicle,  237 
of  wrist,  510 


Treatment,   suppurative   arthritis   in 
infancy,  278 
synovial    tuberculosis    of    knee- 
'  joint.  438 

syphilitic  diseases  of  joints,  273 
talipes  equinovalgus,  associated 
with  congenital  absence  of  the 
fibula.  844 
tenosynovitis  at  ankle-joint,  479 
torticollis,   682 

traumatic   coxa   vara.   587.   588, 
589 
spondylitis.  132 
traumatisms  at  hip- joint,  409 
trigger-finger,  515 
tuberculous     disease     of     ankle- 
joint,  473 
of  bones  and  joints,  261 
of   elbow-joint.  487 
of  hip-joint.   339 
of  knee-joint,  428 
of  shoulder- joint,  484 
of  spine.  66 
of  tarsus.  473 
of  wrist-joint.  490 
typhoid  spine,  132 
weak  foot,  728 
web-fingers,  514 
Trigger-finger,   515 
etiology  of,  515 
treatment  of,  515 
Tuberculosis,    synovial,    arborescent, 
256  ' 
of  knee-joint,  438 

treatment  of,  438 
Tuberculous  arthritis,  acute,  279 
disease  of  ankle-joint.  463 

age    at    incipiency    of, 

465 
astragalo-navicular  dis- 
ease. 467 
deformity  in,  466 
diagnosis  of,  467 
etiology  of,  464 
pathology   of,   463 
prognosis  in.  471 
situation  of,  464 
subastragaloid     disease 

in,  467 
symptoms  of,  465 
treatment  of,  469 
of  bones  and  joints,  247 

arborescent     syno- 
vial, 256 
caries  sicca,  258 
diagnosis  of,  261 
distribution  of  dis- 
ease in,  250 
etiology  of,  247 
extra-articular  dis- 
ease,  254 


INDEX. 


905 


Tuberculous    disease    of    bones    and 

joints,  latent  tu- 

iaerculosis  as 

cause  of,  247 

lipoma        arbores- 

cens,  237 
mode   of  infection 

in,  247 
other  forms  of,  256 
pathology  of,  252 
perforation    of 

joints  in,  254 
predisposition     to, 

247 
prognosis  in,  259 
repair  in,  258 
rice  bodies  in,  257 
septic  infection  in, 

258 
treatment  of,  261 
of  elbow-joint,  485 

age    at    incipiency    of, 

485 
occurrence,  485 
pathology  of,  485 
prognosis,  489 
symptoms,  486 
treatn:ent,   487 
of  hip- joint,  304 
abscess  in,  387 
actual    lengthening    of 
limb  in,  325 
shortening  of  limb 
in,  323 
in  adult,  386 
age    at    incipiency    of, 

308 
amputation  in,  396 
bilateral,  384 
combined  with   disease 

of  other  parts,  385 
correction  of  deformity 
by     femoral     osteot- 
omy, 399 
deformities     of     other 
parts  caused  by,  407 
diagnosis  of,  from  an- 
terior   poliomye- 
litis,  333 
from   arthritis   de- 
formans, 334 
from        congenital 
dislocation        of 
hip,  336 
from     coxa     vara, 

335 
from  bursas   about 

joint,  335 
from      epiphysitis, 

334 
from    extra-articu- 
lar  disease,   334 


Tuberculous  disease  of  hip-joint,  di- 
agnosis of,  from 
fracture  of  neck 
of  femur  in 
childhood,  335 
from       gonorrheal 

arthritis,  334 
from  growing- 
pains,   333 
from         hysterical 

joint,  336 
from        infectious 

arthritis,  334 
from  local  injury, 

333 
from     pelvic     dis- 
ease,  335 
from    Pott 's     dis- 
ease, 334 
from    rheumatism, 

333 
from        sacro-iliac 

disease,  335 
from  scurvy,  333 
from  synovitis,  333 
x-T&ja     as     means 
of,  336 
distortion    of    liml)    in, 

314 
etiology  of,  308 
examination  in,  327 
excision  of  hip  in,  393 
in  infancy,  386 
Koenig's   statistics   of, 

317 
local  signs  of,  332 
measurements   of,  328 
method    of    estimating 
degree  of  distor- 
tion in,  329 
of    recording    case 
in,  336 
mortality  in,  401 
"  natural     cure  "     in, 

316 
pathology  of,  304 
physical  signs  of,  311 
prognosis  of,  401 

as  to  function,  404 

reduction  of  deformity 

in      resistant      cases, 

398 

retardation    of    growth 

in,  324 
sex,  309 

side  affected  in,  309 
sinuses  in,  391 
symptoms  of,  309 
atrophy  of,  320 
change  in   contour 
of  hip  as,  319 


906 


INDEX. 


Tuberculous  disease  of  hip-joint, 
symptoms  of, 
distortion  of 

limb  as,  314 
general,  327 
limp  as,  311 
"  night   cry  "   as, 

310 
pain  as,  310 
stiffness  as,  311 
treatment  of,  339 

during       recovery, 

379 
Lorenz  spica  band- 
age in,  374 
mechanical,   341 
by    plaster    band- 
age, 366 
splints,   374 
reduction     of     de- 
formity in,  347 
splinting  in,  341 
stilting,  341 
Thomas',   359 
traction  hip  splint 
in,  353 
splinting    and 
stilting     in, 
375 
of  the  knee-joint,  417 
abscess  in,  438 

treatment  of,  438 
actual    lengthening    of 
limb  in,  425 
shortening  of  limb 
in,  425 
deformity  in,  444 
diagnosis  of,  426-= — 
from     acute     epi- 
physitis, 427 
from   arthritis   de- 
formans, 427 
from    Charcot  's 

disease,  427 
from      hsemarthro- 

sis,  427 
from  hysterical 

joint,  427 
from  infectious  ar- 
thritis, 427 
from      injury      of 

knee,  426 
from    rheumatism, 

•427 
from  sarcoma,  427 
from  synovitis,  427 
distortions  in,  423 
etiology  of,  420 
extra-articular,  437 
functional     results     of 
treatment  of,  444 


Tuberculous    disease    of    the    knee- 
joint,    limitation    of 
motion,  422 
mortality  in,  443 
occurrence,  420 
operative     intervention 

in,  439 
pathology  of,  417 
prognosis  in,  443 
statistics,  417 
symptoms  of,  420 
synonyms  of,  417 
synovial      tuberculosis, 

438 
treatment  of,  428 
accessory,  435 
amputation  in,  442 
a  r  t  h  r  e  c  1 0  m  y  in, 

439 
Billroth   splint   in, 

430 
excision  in,  440 
forcible   correction 
by  reverse  lever- 
age in,  429 
functional    results 

of,  444 
mechanical,  432 
operation    for    re- 
lief of  final  de- 
formity in,  442 
plaster       bandage 

in,  429 
reduction     of     de- 
formity in,  428 
statistics     of      re- 
sults of,  443 
traction   in,  429 
of  shoulder-joint,  481 

age    at    incif)iency    of, 

482 
pathology  of,  482 
prognosis  of,  484 
symptoms  of,  482 
treatment  of,  4S4 
of  spine,  17 

abscess  in,  109 

treatment  of,  113 
age  at  time  of  onset  of, 

22 
attitude  in,  change  in, 

28 
compensatory     deform- 
ity in,  28' 
complications   of,   109 
contour     of     spine     in, 

changes  in,  28 
deformity  in.  17,  28 
bone,  28 
compensatory,   28 


INDEX. 


907 


Tuberculous    disease    of    spine,    de- 
formity in,   cor- 
rection of,  124 
muscular,  28 
diagnosis    of,     64 
divisions  of  spine,  32 
etiology  of,  22 
impairment     of     func- 
tion in,  28 
later  effects  of  deform- 
ity in,  126 
in    lower    cervical    re- 
gion, 59 
lower  region,  38 
mortality  in,  25 
muscular  deformity  in, 

28 
"  night  cry  ''  in,  28 
pain  in,  27 
paralysis  in,  29,  117 
duration    of,    119 
frequency  of,  117 
liability  to,  in  dif- 
ferent     regions, 
118 
local,  125 
prognosis  of,  121 
symptoms  of,  119 
time    of    onset    of, 

119 
treatment  of,  122 
operative,  123 
pathology  of,  18 
peculiarities     of     lum- 
bar Pott's  disease  in 
infancy,   50 
physical  signs  of,  37 
prognosis  in,  25 
rational  signs  of,  35 
record  of  case  of,  65 
recurrence  of,  126 
relative    frequency    of, 

22 
secondary     deformities 

of,  126 
sex  in,  23 
situation  of  disease  in, 

23 
stiffness  in,  28 
rachitic  spine,  differen- 
tial diagnosis  of,  50 
symptoms  of,  26 

awkwardness,  28 
complicating,  29 
deformity,   28 
general,  30 
secondary,  29 
in  thoracic  region,  51 
abscess  in,  55 
aimless    cough    in, 

54 
attitudes  in,  53 


Tuberculous  disease  of  spine  in  tho- 
racic region,  de- 
viation of  spine 
in,  54 
diagnosis  of,  55 
muscular  spasm  in, 

54 
pain  in,  53 
piigeon  chest  in,  53 
respiration  in,  53 
spinal  cord  involve- 
ment in,  54 
treatment   of,   66 

Bradford     frame 

in,  68 
convex-stretcher 
frame  in,  68 
duration  of,  125 
horizontal    fixation 

in,   67 
indications      for, 

105 
Lorenz     apparatus 

in,  67 
mechanical,   ambu- 
latory    supports 
in,  75 
Phelps  bed  in,  67 
principles  of,  103 
wire     cuirasse     in, 
68 
in  upper  region,  57 
abscess  in,  59 
attitude  in,  58 
symptoms  of,  58 
of  tarsus,  472 

treatment  of,  473 
of  wrist-joint,  489 

age    at    incipiency    of, 

490 
prognosis  in,  490 
symptoms  of,  490 
treatment  of, -490 
tenosynovitis  at  ankle-joint,  479 
Typhoid  sp)ine,  132 

diagnosis  of,  132 
treatment  of,  132 

U 

Unilateral  dislocation  at  the  hip- 
joint,  542 
knock-knee,  605 

V 

Vasomotor  trophic  neuroses,  766 
Vertebrae,  absence  of,  232 
Vertebral  column,  stiffness  of,  133 
Volkmann  seat,  in  treatment  of  lat- 
eral, curvature  of  the  spine,  222 


908 


IXDEX. 


W 

Weak  ankles  in  childhood,  725 
f  oot,\  708 

in  childhood,  7'2i 

deformities      of      legs 

with,  726 
general     weakness     in, 

726 
irregular  forms  of,  725 
outgrown  joints  in,  725 
out-toeing    and    in-toe- 
ing as  symptoms  of, 
724  '    . 

weak  ankles  in,  725 
deformity  in,   709 
diagnosis  of,  717 

attitudes  in,  717 
bearing  surface  in,  719 
contour,  718 
distribution    of   weight 

and  strain  in,  718 
range  of  motion  in,  719 
etiology  of,  713 
extreme  types  oi,  722 
limitation   of  motion,   mus- 
cular spasm  in,  722 
pathology  of,  713 
review  of,   727 
rigid,    737 

functional  use  in  over- 
corrected  attitude  in, 
740 
treatment  of,  738 
adjuncts  in,  745 
forcible      overcor- 
rection in,  738 
operative,    746 
plaster     strapping 

in,  743,  745 
systematic  manipu- 
lation in,  741 
varieties  of,  other,  744 
symptoms  of,  715 
statistics,   714 
treatment,  728 

attitudes  in,  729 


Weak  foot,  treatment,  brace  in,  734 
exercises  in,  730 
shoe  in,  728 
support  in,  730 
varieties  of,  721 
"^"eakness     of     anterior     metatarsal 
arch,  753 
etiology  of,  754 
pathology  of,  754 
treatment  of,  759 
Webbed  finger,  514 
etiology  of,  514 
treatment  of,  514 
Whitman's    operation    for    acquired 

talipes  calcaneus,  863 
Willett  's  operation  for  acquired  tali- 
pes calcaneus,  861 
Wolff 's  law  of  functional  pathogene- 
sis of  deformity,  340 
method    of    correction    of    con- 
firmed club-foot,  826 
Wrenches  in  treatment  of  neglected 

talipes,  828 
Wrist,  deformities  of  congenital,  510 
joint,  tenosynovitis  at,  497 
sprain  of,  496 

chronic,  496 
subluxation  of,  509 
etiology  of,  510 
spontaneous,  509 
treatment  of,  510 
tuberculous  disease  of,  489 
age  at  incipiency  of,  490 
prognosis  in,  490 
symptoms  of,  490 
treatment   of,  490 
vVryneck,  671   {see  Torticollis) 


X-RAYS  as  accessory  in  treatment  of 
tuberculous    disease    of    knee- 
joint,  435 
in  treatment  of  tuberculous  dis- 
ease of  bones  and  joints,  264 


\ 


itilM 


'^■'^%h 


RD731 

'/iJhitman 
Orthopedic  surgery* 


W69 
1910 


rr 


RI>  73  ( 


U/59 


'SM$ 


COLUMBIA  UNlVERSimiBRARlESlhsl.stx) 

RD  731  W59  1910  C.I 


2002311666 


